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  Table of Contents 
CASE REPORT
Year : 2019  |  Volume : 26  |  Issue : 2  |  Page : 110-113  

Postpartum endogenous Candida endophthalmitis


1 Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Ophthalmology, College of Medicine, King Saud University; Dr. Nasser Al-Rashid Research Chair in Ophthalmology, Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Web Publication26-Aug-2019

Correspondence Address:
Dr. Ahmed M Abu El-Asrar
Department of Ophthalmology, King Abdulaziz University Hospital, Old Airport Road, P.O. Box 245, Riyadh 11411
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/meajo.MEAJO_284_18

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   Abstract 


Postpartum endogenous fungal endophthalmitis in otherwise healthy females is extremely rare disease. We report a case of a 25-year-old female patient referred with a history of decreased vision in her right eye 1 month after uncomplicated vaginal delivery. She presented with multifocal chorioretinal infiltrates. The patient showed persistent inflammation in her right eye then after. Systemic workup was unremarkable apart from a history of vaginal discharge during peripartum period. Vaginal swap confirmed the presence of Candida albicans. Culture of the vitreous sample confirmed the growth of C. albicans. The patient was managed with intravitreal amphotericin B in addition to systemic antifungal treatment followed by pars plana vitrectomy. The patient achieved 20/40 vision with quiet eye after 6 months of follow-up.

Keywords: Candida albicans, endogenous endophthalmitis, postpartum


How to cite this article:
AlBloushi AF, Almousa AN, Alkheraiji NF, Abu El-Asrar AM. Postpartum endogenous Candida endophthalmitis. Middle East Afr J Ophthalmol 2019;26:110-3

How to cite this URL:
AlBloushi AF, Almousa AN, Alkheraiji NF, Abu El-Asrar AM. Postpartum endogenous Candida endophthalmitis. Middle East Afr J Ophthalmol [serial online] 2019 [cited 2019 Sep 17];26:110-3. Available from: http://www.meajo.org/text.asp?2019/26/2/110/265373




   Introduction Top


Endogenous fungal endophthalmitis presents usually as a panuveitis with focal or multifocal chorioretinitis. Several predisposing factors have been identified including chronic debilitating diseases, immunosuppression, prosthetic heart valves, intravenous drug abuse, and indwelling venous catheters.[1] Postpartum endogenous Candida endophthalmitis is an extremely rare condition, particularly in healthy individuals. It has been described that, during pregnancy, the rates of vaginal colonization with Candida increase twofold secondary to immune and hormonal changes.[2] Therefore, it may result in transient candidemia during labor that may end up with chorioretinal and vitreous seeding. This report aims to present a case of a 25-year-old female patient who presented with endogenous Candida endophthalmitis 4 weeks after normal vaginal delivery.


   Case Report Top


A 25-year-old female patient with a history of diabetes mellitus on insulin treatment was referred to the emergency room at King Abdulaziz University Hospital with a history of progressive decrease of vision in her right eye 4 weeks after normal vaginal delivery. On the day of examination, her vital signs were stable. Snellen visual acuity was 20/80 in the right eye and 20/20 in the left eye. Intraocular pressure was 14 mmHg in the right eye and 12 mmHg in the left eye. Slit-lamp examination showed corneal fine keratic precipitates, 3+ cells in the anterior chamber, and clear lens in the right eye. Dilated fundus examination of the right eye showed 1+ vitreous haze, hyperemic optic disc, and multiple yellowish-white retinal infiltrates [Figure 1]a. Left eye examination was unremarkable. Fluorescein angiography of the right eye showed diffuse vascular leakage along with optic disc [Figure 1]b. Optical coherence tomography showed dry macula in the right eye.
Figure 1: (a) Color fundus photograph of the right eye showing mild vitreous haze, multifocal chorioretinal yellowish-white infiltrates (arrows), and hyperemic optic disc. (b) Fluorescein angiography of the right eye showing severe optic disc leakage and staining and diffuse retinal vascular leakage

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The patient was admitted with a provisional diagnosis of right acute nongranulomatous panuveitis probably representing atypical toxoplasmosis. Uveitis workup was performed and included complete blood count (white blood cells: 6.600 103/μl), renal and liver function test, purified protein derivative skin test, computerized tomography (CT) of the chest, syphilis and toxoplasmosis serology, erythrocyte sedimentation rate (ESR: 5 mm/h), C-reactive protein (2.85 mg/L), and urine analysis that all came to be negative. Her hemoglobin A1c was 6.7%. The patient was started on empirical anti-toxoplasmosis therapy including clindamycin (300 mg four times daily) and co-trimoxazole (160 mg trimethoprim/800 mg sulfamethoxazole daily), followed by systemic prednisolone 1 mg/kg body weight. She experienced transient mild improvement in her clinical picture that was followed by persistent and unresponsive inflammation. Thereafter, the toxoplasmosis serology came to be negative. After requisitioning the patient about the details of her pregnancy history, she admitted that she had persistent vaginal discharge that was not associated with fever during the peripartum period.

A gynecologist was consulted, and a vaginal swap was obtained which showed heavy growth of Candida albicans. Furthermore, on consultation with the infectious disease team, blood and urine culture; CT chest, abdomen, and pelvis with contrasts; and cardiac echography were performed, which all came to be unremarkable. As the inflammation was not responding and vitritis was increasing, we noticed the appearance of whitish vitreal colonies, which was highly suggestive of fungal infection.

Vitreous tap was performed for cytology, culture, and sensitivity, and empirical intravitreal amphotericin B was given (10 μg/0.1 ml). Cultured vitreous sample showed growth of C. albicans sensitive to amphotericin B and micafungin. The patient was started on intravenous micafungin (100 mg daily for 3 weeks) in addition to pars plana vitrectomy and lensectomy with a complete removal of the vitreous debris and colonies. The aspirated fluid from the vitrectomy cassette was centrifuged and cultured. The results showed persistent growth of C. albicans. Examination 3 months after vitrectomy, her best-corrected Snellen visual acuity was 20/40 and intraocular pressure was 16 mmHg, and slit-lamp examination showed clear cornea with quiet anterior chamber, clear vitreous cavity, and flat retina. Left eye examination was within normal.


   Discussion Top


C. albicans is considered as normal flora of the respiratory and gastrointestinal tracts and is isolated from the female genital system in up to 15%–21% of nonpregnant women.[2] Hormonal and immune changes influence colonization of the genital tract by microorganisms; thus, the prevalence of vaginal infections with C. albicans increases during pregnancy. Candidemia with secondary ocular colonization is an extremely rare condition after normal vaginal delivery.[3] It has been hypothesized that maternal candidemia occurs as a consequence of ascending vaginal infection that invades traumatized genital tract during delivery, causing direct introduction of Candida elements into the vascular system and the subsequent development of candidemia. Once the pathogen has been introduced into the bloodstream, it has the propensity to localize in the organs supplied by end arterioles, such as the choroid.[2],[3] Candida endophthalmitis classically presents as a focal or multifocal chorioretinitis.

In the current case, the diagnosis could not be suspected from the first clinical setting as the patient presented with a picture of panuveitis and normal initial investigation. To the best of our knowledge, there have been seven reported cases of postpartum endogenous fungal endophthalmitis, all of which were due to C. albicans infection [Table 1]. In comparison with our study, all these cases presented earlier in <14 days postpartum; however, our case presented late 4 weeks after delivery. Final visual acuity in patients with Candida endophthalmitis is variable; however, prompt diagnosis and treatment with the proper antifungal agents may lead to a favorable visual outcome. In agreement with the previous reports, our patient achieved 20/40 vision during the follow-up.[2],[3],[4] Moreover, our case also demonstrated that the combination of intravitreal amphotericin B and systemic antifungal treatment along with early therapeutic pars plana vitrectomy leads to a favorable visual prognosis. This is in agreement with the previous reports.[2],[5] Therefore, vaginal discharge during the peripartum period associated with significant ocular inflammation should raise the suspicion of endogenous Candida endophthalmitis in the differential diagnosis.[2],[3],[6], [7] Moreover, prompt and multidisciplinary team assessment is essential in the workup, diagnosis, and the treatment of such cases.
Table 1: Case reports of postpartum fungal endophthalmitis

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   Conclusion Top


Postpartum endogenous Candida endophthalmitis in otherwise healthy individuals is a rare entity. Early recognition and treatment are essential to achieve better visual outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

The authors would like to thank Ms. Connie B. Unisa-Marfil, for secretarial assistance. This work was supported by King Saud University through Vice Deanship of Research Chair, Dr. Nasser Al-Rashid Research Chair in Ophthalmology (Abu El-Asrar MA).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Scherer WJ, Lee K. Implications of early systemic therapy on the incidence of endogenous fungal endophthalmitis. Ophthalmology 1997;104:1593-8.  Back to cited text no. 1
    
2.
Tsai CC, Chen SJ, Chung YM, Yu KW, Hsu WM. Postpartum endogenous Candida endophthalmitis. J Formos Med Assoc 2002;101:432-6.  Back to cited text no. 2
    
3.
Wu JS, Chen SN, Hwang JF, Lin CJ. Endogenous mycotic endophthalmitis in an immunocompetent postpartum patient. Retin Cases Brief Rep 2011;5:10-3.  Back to cited text no. 3
    
4.
Cantrill HL, Rodman WP, Ramsay RC, Knobloch WH. Postpartum Candida endophthalmitis. JAMA 1980;243:1163-5.  Back to cited text no. 4
    
5.
Lee JH, Kim JS, Park YH. Diagnosis and treatment of postpartum Candida endophthalmitis. J Obstet Gynaecol Res 2012;38:1220-2.  Back to cited text no. 5
    
6.
Guex-Crosier Y, Chave JP, Herbort CP. Postpartum Candida endophthalmitis treated with fluconazole. Ophthalmologica 1993;206:214-5.  Back to cited text no. 6
    
7.
Michelson PE, Stark W, Reeser F, Green WR. Endogenous Candida endophthalmitis. Report of 13 cases and 16 from the literature. Int Ophthalmol Clin 1971;11:125-47.  Back to cited text no. 7
    


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