Infectious endotheliitis: a rare case of presumed mycotic origin

Abstract

PurposeTo report an interesting case of infectious endotheliitis of presumed mycotic origin.MethodsA case report of a 56-year-old male farmer who sought medical attention after a month-long evolution of irritative symptoms in his right eye, accompanied by visual acuity (VA) impairment. The patient received topical and oral broad-spectrum antibiotic treatment with no improvement before being referred to a cornea specialist, where he was found to have VA of 20/150 and was noted on biomicroscopy to have endothelial feathery coalescent lesions. The patient was admitted to the hospital for an aqueous humor sample and intravenous voriconazole.ResultsThe microbiological studies did not isolate any micro-organisms. However, clinical evidence of improvement was confirmed after 5 days of antimycotic intravenous therapy. Complete clinical resolution was achieved at 1 month after treatment completion with oral voriconazole, as evidenced by VA of 20/20 and disappearance of endothelial lesions.ConclusionEndothelial involvement by fungi is a rare condition. In this case, no microbes were isolated, but the characteristic morphology of the lesions, the history of onychomycosis, and the spectacular response to voriconazole turn this case into a valid presumptive diagnosis.

A Review of Corneal Endotheliitis and Endotheliopathy: Differential Diagnosis, Evaluation, and Treatment

“…In 2012, Garg [85] noted several fungal etiologies that infect the corneal epithelium which, if left untreated, have the potential to extend into the endothelium and cause decompensation and inflammation. In 2013, Zapata et al [86] reported a case of infectious endotheliitis of suspected mycotic origin. Although no organisms were isolated, clinical improvement was seen after 5 days of antimycotic therapy.…”

“…If neither viral PCR nor bacterial culture return positive, further etiologies must be investigated. Fungal culture and/or a trial of antimycotic treatment may be warranted [86]. In vivo confocal microscopy can reveal KP and other lesions that might suggest another cause [111].…”

“…However, coalescent circular endothelial lesions with a feathery and white appearance may be revealed by in vivo confocal microscopy. If these lesions are seen, or if there are other reasons in the patient’s history to suggest a fungal infection, intravenous voriconazole 200 mg every 12 h for 5 days [86] and 0.15% topical amphotericin B prepared from fungizone may be initiated [115]. Some patients may require adjunct intracameral or intrastromal antimycotic injections [86, 116].…”