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      Candida albicans scleral abscess in a HIV-positive patient and its successful resolution with antifungal therapy—a first case report

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          Abstract

          Background

          Fungal infection of the sclera is very rare. No case of fungal scleral abscess in a HIV-positive patient has been reported. We report a case of scleral abscess caused by Candida albicans and its successful resolution following antifungal therapy in a HIV-positive patient.

          Findings

          A 57-year-old diabetic Asian (Indian) who was on highly active antiretroviral therapy for the last 10 years presented with 2 weeks’ history of redness in his right eye. Examination revealed localised scleral inflammation with central ulceration in the inferior quadrant of the right eye. Initially, the ulcer scrapings revealed no microbial organism. Progression of ulcer although on empirical antibiotic therapy required repeat scrapings which showed Candida albicans species in culture sensitive to amphotericin and natamycin. Aggressive topical and systemic antifungals resulted in dramatic and complete healing of the ulcer in 3 weeks. Vision was well maintained at 20/30 throughout the treatment course, and the fundus remained normal.

          Conclusions

          This is the first ever case of fungal scleral abscess in a HIV patient to be reported emphasizing there is a need for high vigilance to suspect an infective aetiology of scleritis in patients with immunocompromised status. Prompt microbial assessment and appropriate antifungals can decrease morbidity in these unusual but serious cases as illustrated in this case.

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          Most cited references 20

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          Clinical experiences of infectious scleral ulceration: a complication of pterygium operation.

          To report the special clinical manifestations and determine the appropriate management of infectious scleral ulceration. A retrospective study was performed on 30 eyes with infectious scleral ulceration. Information was recorded on patients' age, onset and course of disease, pathogenic organism, clinical presentations, methods of diagnosis, treatment, and outcome. 10 cases (33.3%) were accompanied by corneal involvement. Subconjunctival abscess was noted in 16 cases (53.3%). 17 cases (56.7%) gave positive results of pathogen culture and all were Pseudomonas aeruginosa. Two cases had combined bacterial infections and one case was complicated by fungal infection. A total of 26 cases had surgical debridement in this series. Extensive involvement of the sclera with the presence of a 'tunnel lesion' or a 'satellite subconjunctival abscess' were found during debridement. All of the eyeballs involved were salvaged except one. The results of this study were contrary to the poor prognosis presented in previous reports. Early and repetitive surgical debridement is believed to be mandatory in the intractable cases to shorten the admission period and to save these eyes.
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            Microbial scleritis-experience from a developing country.

            The purpose of this article was to study the clinical features, pathogenic organisms, and the outcome in cases of infectious scleritis. Retrospective chart review of all patients of infectious scleritis examined from January 2000 to February 2005 in the cornea services of L.V. Prasad Eye Institute, Hyderabad, India was done. Information including patient's age, predisposing factors, clinical presentation, pathogenic organism, methods of diagnosis, treatment, and outcome were abstracted from the medical records. A total of 21 eyes of infectious scleritis were identified. All except three eyes had preceding predisposing factors, prior cataract surgery (6 eyes) (30%) and pterygium surgery (5 eyes) (23.8%) were the most common predisposing factors. Fungus (8 eyes) (38%), either alone (5 eyes) (24%) or as mixed infection (3 eyes) (14%), was the most common offending organism. Nocardia was identified in five eyes (24%) and Pseudomonas aeruginosa in two eyes (10%). Seven eyes (33%) had accompanying corneal infiltration. Multifocal scleral abscess was seen in three eyes (14%) and endophthalmitis was seen in three eyes (14%). During the course of treatment, five eyes (24%) were complicated by serous retinal or choroidal detachment and five eyes (24%) with progression of cataract. Surgical debridement was carried out in 14 eyes (67%). Four eyes (19%) were eviscerated. Useful vision, defined as visual acuity > or = 20/200, could be preserved with treatment in seven eyes (33%). Although predisposing factors were similar, fungi and Nocardia were the most common etiological agents in this series and the clinical outcomes were poorer.
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              Intrascleral dissemination of infectious scleritis following pterygium excision.

              To assess the clinical pictures, possible pathogenesis, management, and therapy of patients with infectious scleritis associated with multifocal scleral abscesses following pterygium excision. The records of patients with infectious scleritis after pterygium excision who developed multifocal scleral abscesses presenting from 1988 to the end of 1995 were reviewed. Early culture of abscesses was performed, and topical, systemic antimicrobials, or both were given to all patients. Fourteen eyes were operated on in addition to antimicrobial treatment. The initial culture reports of scleral ulcers identified Pseudomonas species in 12 of these 18 patients, Aspergillus in one, Mycobacterium fortuitum in one, and mixed organisms in four. Subsequent abscess cultures were taken from 15 of the infected eyes, and revealed the same organism as the initial culture in 12. Associated complications included four serous retinal detachments, three choroidal detachments, two double detachments, five complicated cataracts, and four recurrences of the initial infection. Four eyes required eventual enucleation and 11 eyes regained useful vision. With subsequent abscess cultures proving to be the same organism as found in the initial ulcer, the abscess formation appears to represent intrascleral dissemination. Early diagnosis and appropriate, prolonged topical plus systemic antimicrobial treatment are essential to halt the progression of such severe infections.
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                Author and article information

                Contributors
                9841428151 , +91-44-28271616 , drjb@snmail.org
                Journal
                J Ophthalmic Inflamm Infect
                J Ophthalmic Inflamm Infect
                Journal of Ophthalmic Inflammation and Infection
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                1869-5760
                22 June 2016
                22 June 2016
                2016
                : 6
                Affiliations
                [ ]Medical Research Foundation, Sankara Nethralaya, 18, College Road, Chennai, 600 006 Tamil Nadu India
                [ ]Uveitis and Ocular Pathology Department, Sankara Nethralaya, 18, College Road, Nungambakkam, Chennai 600 006 India
                Article
                92
                10.1186/s12348-016-0092-1
                4917511
                27334612
                © The Author(s). 2016

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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                © The Author(s) 2016

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