A 68-year-old hospitalized woman is evaluated due to decreased vision in the left eye. The patient has a history of advanced ovarian cancer and has been treated with combination chemotherapy. Three weeks ago, she was admitted to the hospital with small bowel obstruction. There was no improvement with nonoperative management, so she underwent exploratory laparotomy and bowel resection 14 days ago. The postoperative course was complicated by an anastomotic leak. The patient is receiving total parenteral nutrition and piperacillin-tazobactam. Over the past 2 days, she has had floaters and progressive blurring of the vision in the left eye. The patient reports no eye pain or headache. Temperature is 38 C (100.4 F), blood pressure is 122/80 mm Hg, and pulse is 96/min. Left eye visual acuity is decreased, and funduscopy reveals fluffy, yellow-white chorioretinal lesions with ill-defined borders. The central venous catheter site has no erythema or tenderness. There is no discharge from the abdominal incisions. Which of the following is the most likely cause of this patient's ocular symptoms?
Candida endophthalmitis | |
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TPN = total parenteral nutrition. | |
This patient has unilateral decreased vision, floaters, and fluffy, yellow-white chorioretinal lesions, indicating Candida endophthalmitis, a yeast infection of the structures and (usually) fluid chambers of the eye. Most cases arise in hospitalized patients with central venous catheters, which allow a portal of entry from the skin to the bloodstream. Risk is increased with total parenteral nutrition, immunocompromise (eg, cancer, chemotherapy), broad-spectrum antibiotics, and recent abdominal surgery.
Candida typically spreads to the highly vascular choroid layer via hematogenous dissemination during transient or persistent fungemia. The organism replicates in the choroid and attacks the retina, leading to fluffy, yellow-white, mound-like lesions with indistinct borders. It then spreads into the vitreous or aqueous fluid chambers. Floaters and progressive loss of vision develop first; eye pain occurs late in the disease course. Systemic symptoms (eg, fever) often occur when fungemia is present.
Although central catheters are usually the portal of entry, the catheter insertion site often appears normal (eg, no pus or erythema). In the presence of suggestive fundoscopic findings, blood cultures and, in some cases, vitreous fluid sampling can be used for diagnosis. Systemic antifungals (eg, fluconazole) and vitreous antifungal injection/vitrectomy (when the vitreous is involved) are the mainstays of treatment.
(Choice A) Brain metastases can occur in ovarian cancer; however, vision abnormalities from space occupying lesions are typically marked by signs of increased intracranial pressure (eg, bilateral papilledema). Floaters and fluffy, yellow-white retinal lesions do not occur.
(Choice B) Risk for drug-induced glaucoma is greatest with glucocorticoids, systemic sympathomimetics (eg, ephedrine), and systemic anticholinergics. Piperacillin-tazobactam is not a common cause. Furthermore, optic disc cupping, not fluffy retinal lesions, would be seen on funduscopic examination.
(Choice D) Paraneoplastic optic neuritis is uncommon and usually seen with small cell lung cancer. It can cause acute unilateral vision loss but is often painful. Furthermore, papillitis is seen on funduscopic examination.
(Choice E) Vitamin A deficiency is most common in those who have undergone bariatric surgery or have severe malnutrition. Most patients have xerophthalmia, excessive dryness of the conjunctiva/cornea that causes ridges. This patient with fluffy, yellow-white spots on the retina likely has Candida endophthalmitis.
Educational objective:
Candida endophthalmitis occurs primarily in hospitalized patients with central venous catheters. It typically presents with floaters and progressive vision loss; pain is absent until late in the disease course. Funduscopy shows fluffy, yellow-white chorioretinal lesions.