Disseminated fusariosis with endophthalmitis in a patient with hematologic malignancy

Perini, Guilherme Fleury; Camargo, Luis Fernando Aranha; Lottenberg, Claudio Luiz; Hamerschlak, Nelson

doi:10.1590/S1679-45082013000400026

LEARNING BY IMAGES

Hospital Israelita Albert Einstein, São Paulo, SP, Brazil

Correspondence

A 68-year-old patient previously diagnosed with acute myeloid leukemia had fever and myalgia during chemotherapy. Despite broad spectrum antibiotics, fever persisted and, after 3 days, skin lesions compatible with Fusarium infection were seen on patients' lower limbs. Dyspnea and hypoxia were observed, and computerized tomography showed extensive pulmonary infiltrates; blood cultures were positive for Fusarium sp. A diagnosis of disseminated fusariosis was done, and lipossomal amphotericin, voriconazole and granulocyte infusion were initiated.

The patient had complete regression of skin lesions and pulmonary infiltrates, but a week later he complained of visual blurring in the left eye. An orbital magnetic resonance imaging showed enhancement of left ocular globe with a lateral, medial and anterior delamination that was compatible with endophthalmitis (Figure 1). An intraocular treatment with voriconazole was applied and a little improvement was seen. Fusarium sp endophthalmitis affecting his right eye was diagnosed, which justified his visual loss. Despite treatment, a progressive worsening of bilateral endophthalmitis occurred and, to control the disease, the eye was enucleated. The pathological examination of the enucleated eye showed an intraocular abscess adjacent to the retina (Figure 2). In a higher magnification, Fusarium hyphae could be identified (Figure 3).

Fusarium species cause a broad spectrum of infections in humans, including superficial, locally invasive, and disseminated infections. Immunocompromised patients are at higher risk, especially those with prolonged and severe neutropenia and/or severe T-cell immunodeficiency⁽¹⁾. Patients with acute leukemia and patients undergoing hematopoetic stem cell transplantation are particularly at risk, especially to the invasive and disseminated⁽²⁾ forms. The typical pattern of disseminated disease is a combination of cutaneous lesions (often with external necrosis in the center of the lesion), positive blood cultures, and with or without involvement at other sites (sinuses, lungs, and others)⁽³⁾.

Fusarium endophthalmitis in the immunocompromised host usually results from hematogenous seeding^(4,5). Intraocular and systemic therapies often have poor responses. In order to avoid central nervous system involvement, the evisceration of the eye may be necessary⁽⁶⁾. Few case reports describe successful treatment of Fusarium sp endophthalmitis with voriconazole alone or in combination with caspofungin and posaconazole^(7,8).

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