Candida(Amphotericin-Sensitive) Lens Abscess Associated With Decreasing Arterial Blood Flow in a Very Low Birth Weight Preterm Infant

Abstract

ABSTRACT. In this report, we review the case of a candidal lens abscess in a premature infant girl who was 28 weeks' gestational age at birth. The culture obtained from the lens abscess grew Candida albicans sensitive to amphotericin B but resistant to flucytosine. This case is unique in that the infant developed a fungal lens cataract at 34 weeks' postconceptional age during the last week of a 30-day course of amphotericin B. The embryonic hyaloid artery system, which perfuses the developing lens, regresses between 29 and 32 weeks of gestation; thus, the mechanism for an infection of the lens may be inoculation of the lens by Candida before hyaloid artery system regression, followed by developmental loss of this blood supply, which makes the lens inaccessible to antimicrobial penetration. Candidal endophthalmitis with lens abscess is an uncommon morbidity that requires prompt recognition and surgical intervention for effective management. A lthough Candida chorioretinitis is the most common presentation of an intraocular infection in the premature infant, candidal lens abscesses are uncommon. [1][2][3][4] An abscess in the lens, an apparently avascular structure, should be unlikely. However, during early embryologic development the lens has a blood supply from the hyaloid artery system supplied by the hyaloid artery, a tributary of the main ophthalmic artery. The hyaloid artery approaches the lens from the posterior side, supplying the posterior portion of a network of vessels enveloping the lens, the tunica vasculosa lentis (TVL). The TVL is also supplied along its equatorial margin by vascular branches fed by the long ciliary arteries. 5 The hyaloid artery regresses later in gestation. A transparent remnant, the canal of Cloquet is found when the lens becomes avascular. The TVL also involutes, generally later than the hyaloid artery. Once the hyaloid artery involutes, the TVL is then completely supplied by the long ciliary arteries. [5][6][7] We report a case of candidal endophthalmitis with lens abscess formation presenting initially as a cataract in a preterm infant at 30 weeks' postconceptual age. This case is unique because the infant developed the fungal cataract during systemic antifungal treatment. The cataract progressed to a Candida albicans lenticular abscess and endophthalmitis confirmed by lens culture. Aggressive surgical intervention and antifungal injection into the vitreous were required to resolve this infection and to salvage the left eye. CASE REPORTAn infant girl was 28 weeks' gestational age at birth and weighed 1020 g. The pregnancy was complicated by premature labor at 24 weeks and premature rupture of membranes at 27 weeks' gestation. Initial sepsis evaluation was negative, and she received 5 days of ampicillin and gentamicin. She had 5 days of conventional mechanical ventilation for respiratory distress syndrome and was extubated to room air on day of life (DOL) 5. On DOL 16 (30 weeks' postconceptional age) she developed apnea and bradycardia requiring intubation and ventilatory suppo...

Candida species lens abscesses in infants with a history of neonatal Candida sepsis

“…Others have also noted the difficulty of culturing Candida from eyes with Candida lens abscesses. 1, 4, 6, 8-10 Our findings emphasize the importance of sampling lens/vitreous aspirate and anterior chamber membranes rather than aqueous humor for Candida in these cases. In addition, it is necessary to observe cultures for an extended period of time since Candida can take several weeks to grow (3-13 days in this series).…”

“…The tunica vasculosa lentis is patent in the majority of premature infants until a PMA of 28 to 34 weeks; by a PMA of 38 weeks nearly all will have undergone total regression. 5, 6 Fenestrations on the lenticular side of the tunica vasculosa lentis may serve as conduits for fungal organisms to seed the crystalline lens during candidemia (Figure 3a). 7 After the tunica vasculosa lentis regresses, a lens abscess may then develop since systemically administered anti-fungal agents can no longer enter the lens (Figure 3b).…”

Endogener Candida-Linsenabszess bei Frühgeborenem

“…Gestationswoche vorliegen kann und in der 38. Gestationswoche sich fast sämtliche Gefäße zurückgebildet haben [4,7]. Eine Ausbreitung über diesen Mechanismus wäre bei dem hier beschriebenen Kind möglich gewesen.…”

“…Dies war bei dem vorgestellten Kind aber nicht der Fall. Im Gegensatz zu Chorioretinitis und Endophthalmitis ist das Auftreten eines Candida-Linsenabszesses ausgesprochen selten und bisher erst 10-mal in der Literatur beschrieben worden ([2][3][4][8][9][10];. Tab.…”

Low Yield of Ancillary Diagnostic Studies in Neonates Infected with Candida

“…[3][4][5]9 The occurrence of end-organ involvement and morbidities associated with candidal infection is less well defined, documented most often in case reports and small clinical series. There have been reports of neonates with candidal lens and retinal involvement, [10][11][12][13][14] but information regarding the incidences and natural history of candidal renal mycetoma, fungal endocarditis, and fungal brain abscesses among neonates is limited. [15][16][17][18][19][20][21][22][23][24] Ancillary testing including retinal examination, abdominal ultrasound and echocardiogram for all infants with candidemia has been suggested.…”