First Author: G.Moussa UK
Co Author(s): J. Panthagani S. Shakir S. Madge
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To describe the first reported case of bilateral endogenous endophthalmitis secondary to fungal septic emboli originating from the sphenoidal sinus spreading to the cavernous sinus and the internal carotid artery, in an immunocompetent 87-year-old Caucasian gentleman; presenting with panuveitis.
Acute admission for 87-year-old hospital with loss of vision presenting at Hereford County Hospital, UK.
Inpatient ophthalmic care with regular review, photography, MRI, PET, OCT-Angiography, blood tests, vitreous biopsy investigations.
A patient with radiotherapy treated sphenoidal sinus malignancy 20 years previously, presented with acute loss of vision in the right eye (RE). Visual acuity (VA) RE: CF. RE showed panuveitis; vitritis and multiple areas of haemorrhagic retinal necrosis with a normal left eye. Presumed to be of viral origin, Vitrectomy with biopsy showed negative culture and PCR and found full thickness retinal necrosis with fungal-like subretinal collections. After multiple TIAs, MRI found multiple recent embolic infarcts throughout distribution of right thickened internal carotid, and sphenoidal sinus thickening; this grew Aspergillus versicolour on endoscopy. The intensity signals on MRI were consistent with that with fungal infection. Retinal tissue gram stain showed gram-positive filamentous branching rods without acid fast stain, assumed to be actinomycosis. A right superior ophthalmic vein thrombosis developed causing right ophthalmoplegia. The LE developed the same lesions after two weeks, intensive systemic antiviral, antifungal and antibacterial therapy presenting initially with a mild vitritis.
This case describes systemic pathology presenting in the eye in a novel manner. We discuss the diagnostic challenge and journey in this complicated case. Unfortunately, the patient passed away despite maximal treatment and investigation with full collaboration between specialities. We hope to provide insight to other similar complex cases.