Aspergillus terreus – A rare cause of post-operative endophthalmitis: Case report

We report a case of post-operative endopthalmitis following cataract surgery due to Aspergillus terreus in a 54-years-old patient who presented with pain, redness, watering of eye, and decreased vision after one month of surgery. Aspergillus terreus was isolated from vitreous fluid, vitrectomy was performed, systemic and intravitreal amphotericin B was given, but the patient did not respond, and enucleation had to be performed. The case report highlights importance of prompt and proper diagnosis of Aspergillus terreus endophthalmitis as this agent often shows resistance to amphotericin B.

Keywords: Aspergillus terreus , post-operative endophthalmitis, vitrectomy

Aspergillus fumigatus and Aspergillus flavus comprise of majority of Aspergillus endophthalmitis infections. ^[1],[2] Aspergillus terreus was initially considered as common laboratory contaminant. Since the first case report in 1991, it has been reported as a rare cause of endopthalmitis. ^[3],[4] Here, we report a case of endopthalmitis due to this rare agent in a post-operative patient, in which enucleation had to be performed.

A 54-year-old man presented with pain, redness, and watering of right eye since 15 days. He also complained of reduction of vision in the same eye. The patient was operated for cataract of right eye one month back and referred for further management.

On examination, visual acuity in the right eye was perception of light with accurate projection. Conjunctiva showed edema and hyperemia. Cornea showed stromal edema along with hypopyon formation [Figure 1]. The anterior chamber appeared shallow. Therapeutic keratoplasty was performed. As inflammation was observed, conjunctival swabs were sent for microbiological investigation, which showed growth of Aspergillus terreus. Meanwhile, patient’s corneal button was also sent, which also showed growth of Aspergillus terreus. As post-operative endopthalmitis was suspected, vitrectomy was planned; intravitreal and systemic gentamycin, vancomycin was started. Intravitreal amphotericin B was also given. Vitrectomy was performed. Vitreous sample was cultured on Sabouraud’s Dextrose agar, which after 48 hours of incubation at room temperature grew white fluffy colonies with brown pigmentation [Figure 2]. Lactophenol cotton blue mount of culture showed hemispherical vesicle covered with biseriate phialides bearing smooth conidia characteristic of Aspergillus terreus [Figure 3]. The same finding was observed by putting slide culture on potato dextrose agar. The patient did not respond to treatment; enucleation of the right eye was performed.

Aspergillus endopthalmitis is a relatively rare condition encountered in clinical practice. Endogenous endopthalmitis is reported in immunocompromised individuals. Exogenous aspergillus endophthalmitis is reported following cataract surgery, keratoplasty, and eye trauma. ^[1],[5] Aspergillus terreus was first reported as a cause of endopthalmitis in a patient with chronic lymphocytic leukemia. Das T et al. from India reported the first case of post-operative endopthalmitis. ^[4] The reason for the infrequent reporting of Aspergillus terreus endopthalmitis could be due to the fact that this organism is often considered as laboratory contaminant. ^[2],[3] Recently, in the year 2011, Bradley JC et al. reported a case of endogenous Aspergillus terreus endopthalmitis in a 71-years-old male patient who had lung adenocarcinoma and was on chemotherapy. ^[3] The fungus was also recovered from bronchoalveolar lavage and sputum. The patient took only oral fluconazole, and the outcome was fatal as the antimicrobial therapy for aspergillus endopthalmitis consists of intravitreal and intravenous amphotericin B. Since A. terreus often exhibits resistance to amphotericin B in up to 98% of isolates, other alternative antifungals include systemic itraconazole, voriconazole, and caspofungin. ^[2],[4] Hence, high index of clinical suspicion and early microbiological diagnosis of fungal endophthalmitis due to A. terreus is required to start appropriate antifungal treatment for better outcome.^[6]

Source of Support: Only departmental support, Conflict of Interest: None

DOI: 10.4103/1755-6783.140259

[Figure 1], [Figure 2], [Figure 3]