Download Full Text (368 KB)
Summary: An immunocompromised patient with candida tropicalis fungemia secondary to chemotherapy presented for follow up of candida chorioretinitis. This infection puts the patient at high risk for CNVM formation and must be followed closely. Case History: • 3-year-old Hispanic female • CC: Candida chorioretinitis follow up • POH: Bilateral orbital chloromas and optic nerve atrophy • PMH: Acute myeloid leukemia, Candida tropicalis fungemia • Meds: o Amphotericin B liposomal 85 mg 42.5 mL, IV, q24hr o Flucytosine 500 mg Capsule *NF* 1,000 mg 2 capsule, PO/NG, q6hr o Micafungin 100 mg 100 mL, IV, q24hr *Plus numerous chemotherapy, pain and other systemic medications. Pertinent Findings: •Clinical: o DFE: One small, <1/2 disc diameter, white lesion inferior to macula OD. Slightly elevated with pigmented borders • Physical: o Immunocompromised • Laboratory testing: o Culture confirmation of Candida tropicalis fungemia o MRI: innumerable foci of nodular and ringlike contrast enhancement involving the brain, brainstem, and cerebellum most compatible with CNS dissemination of fungal disease. There is additional dissemination of fungal disease with involvement of the orbits and scalp. The presence of restricted diffusion within the rim-enhancing collection of the right orbit as described on the CT examination is most compatible with an abscess. Differential Diagnosis: • Toxoplasmosis • White dot syndrome • Cotton wool spot • Retinal tuft Diagnosis Discussion: Immunocompromised patients are susceptible to life threatening infections that are otherwise rare in the immunonormal. With any concern for infection, a thorough work up is needed to initiate proper treatment quickly. In this patient, cultures were positive for Candida tropicalis fungemia. Amphotericin B, micafungin and flucytosine were started. A baseline eye exam was performed and bilateral candida chorioretinitis was diagnosed. Two lesions near the macula OD and one lesion in the periphery OS were observed. After continuous antifungal treatment, only one lesion with pigmented edges remained near the macula OD and no lesions OS at 1 month follow up. With no additional signs to suggest active infection, pigmentation around the remaining lesion led to diagnosis of inactive candida chorioretinitis. Treatment/Management Discussion: Although the infection appears to be inactive, it is crucial to follow this patient every 6 weeks while the patient remains immunocompromised due to high risk of reactivation. There is also risk of CNVM formation. With the lesion’s close proximity to the macula, this must be carefully monitored with DFE and fundus imaging at every 6 week exam. In addition, it is anticipated the reflex seen during retinoscopy will be altered if changes to the macula occur. Alteration in the reflex would be an additional sign leading to the assumption the disease has progressed. The patient should continue taking systemic antifungals as prescribed by infectious disease team until instructed otherwise. Due to this patient’s young age, and still being within the visual development period, it is important to monitor for amblyopia since the lesion resides within the macula. With the patient having equal 20/50 acuity OD and OS, no amblyopia treatment is indicated at this time, but will be closely watched. Conclusion: Immunocompromised patients are predisposed to life threatening infections. In individuals with a history of infection, it is imperative to follow them closely, no matter if the infection is active or inactive. This group is at a higher risk of reactivation, thus should be monitored until the immune system recovers. In patient’s with any form of chorioretinitis, there is a risk of CNVM formation, even once immunonormal. Careful DFE and imaging should be performed at every follow up.
Valkner Krause, Jourdan, "Candida Chorioretinitis in Immunocompromised Patient with Candida Tropicalis Fungemia Secondary to Chemotherapy" (2023). Posters. 346.