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   Table of Contents      
BRIEF REPORT
Year : 2003  |  Volume : 51  |  Issue : 3  |  Page : 255-257

Prolapsed Intraocular Aspergilloma Masquerading as Malignant Melanoma


Oculoplastic Service, Dr. R.P. Centre for Ophthalmic Sciences, AIIMS, Ansari Nagar, New Delhi, India

Correspondence Address:
Mandeep S Bajaj
Oculoplastic Service, Dr. R.P. Centre for Ophthalmic Sciences, AIIMS, Ansari Nagar, New Delhi
India
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Source of Support: None, Conflict of Interest: None


PMID: 14601852

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  Abstract 

We describe an aspergilloma that masqueraded as an intraocular malignant melanoma in an elderly male patient.

Keywords: Aspergilloma, malignant melanoma, corneal ulcer, trauma, enucleation


How to cite this article:
Bajaj MS, Pushker N, Kulkarni A, Kashyap S, Purohit A. Prolapsed Intraocular Aspergilloma Masquerading as Malignant Melanoma. Indian J Ophthalmol 2003;51:255-7

How to cite this URL:
Bajaj MS, Pushker N, Kulkarni A, Kashyap S, Purohit A. Prolapsed Intraocular Aspergilloma Masquerading as Malignant Melanoma. Indian J Ophthalmol [serial online] 2003 [cited 2019 Nov 12];51:255-7. Available from: http://www.ijo.in/text.asp?2003/51/3/255/14673

Aspergillus is a saprophytic mold found ubiquitously. The spectrum of illness associated with it ranges from allergic reactions to colonisation of damaged tissue, to invasion and destruction of tissue.[1] It rarely affects the eye and has been linked to both exogenous and endogenous aetiologies.[2],[3]

We describe a patient who presented with a black mass in the region of the cornea, masquerading as an intraocular malignant melanoma, both clinically and on imaging studies. To the best of our knowledge, such a case has not been reported in the literature (Medline).

Case report

A 70-year-old healthy male presented to us with bleeding from his left eye followed by gradual appearance of a blackish coloured mass one week before presentation. He had a history of trauma to his left eye with a stone 6 months earlier, following which he developed a corneal ulcer. Since then he had poor vision in the left eye with persistent redness and mild intermittent pain for which he received topical antibiotic therapy. On ocular examination, the visual acuity was 6/6 in the right eye and no light perception in the left eye. Examination of the right eye was within normal limits. Slitlamp examination of the left eye revealed a solid, greyish-black mass, measuring about 12 x 12 mm in size, with blood clots over its surface. It was prolapsing out of a large inferonasal corneal perforation and was 7 mm in diameter [Figure - 1]. The surrounding bulbar conjunctiva was intensely congested with diffuse corneal oedema and scarring. The anterior chamber was shallow and the iris details could not be appreciated. There was no evidence of systemic disease.

Ultrasound (A and B scan) of the left eye revealed a mass lesion occupying the entire vitreous cavity. It was in continuation with the clinically visible mass. The mass had medium to high internal reflectivity spikes with acoustic hollowing [Figure - 2]. Computed tomographic scan (orbit) showed a heterogenous mass in the left vitreous cavity involving the sclera and protruding through the cornea [Figure - 3]. The mass was completely excised, flush with the corneal surface and the corneal defect was repaired with an 8-0 monofilament nylon suture, after which a standard enucleation procedure was performed. Both the specimens were subjected to histopathological examination. Postoperatively, the patient was started on systemic and local antibiotics and anti-inflammatory drugs.

Gross examination of the enucleated eyeball revealed a distorted globe with a corneal perforation to which lens material was adherent. On cut section the entire eyeball was filled with a reddish brown haemorrhagic mass. The anterior chamber, iris and ciliary body could not be discerned. The second specimen was a brownish black mass which was well circumscribed, soft in consistency, measuring 10mm in diameter.

Microscopic examination of the eyeball revealed fresh haemorrhage in the anterior chamber, vitreous, and choroid. In the region of the lens, only the lens capsule could be identified. The retrolental space showed chronic inflammatory cell infiltrate and fibroblastic proliferation, along with fresh haemorrhage. Retinal pigment epithelium could be identified but neural retina was not seen. No fungal hyphae were seen in the sections of the eyeball. Sections from the excised mass revealed areas of fresh haemorrhage and necrosis, with acute inflammatory exudate. Uveal pigment was also identified within this mass along with numerous unstained fungal hyphae. Special staining for fungus with silver methenamine stain revealed septate, acute angle branching fungal hyphae, confirming the diagnosis of aspergilloma [Figure - 4].

As we did not clinically suspect an infection in this case, the specimens were not subjected to culture. Since the tissue had already been fixed in formalin, no further growth of the fungus was possible. In view of aspergillus infection, the patient was postoperatively subjected to the following investigations: chest X-ray, blood studies including bacterial and fungal cultures, urine analysis and Mantoux test. All the tests were within normal limits. Serum immunoglobulins were normal. The patient tested seronegative for HIV on ELISA test. A smear from the conjunctival sac was also negative on culture. A final diagnosis of prolapsed intraocular aspergilloma with suprachoroidal and vitreous haemorrhage was made. Since the complete nidus of fungi was surgically removed and on investigation, no other focus of infection was detected, antifungal therapy was not initiated for the patient. On a follow-up of 3 months, recurrence of infection was not observed.

Discussion

The clinical appearance and imaging studies in this patient were suggestive of a melanocytic tumour arising from the uveal tissue with a high probability of malignancy at his age. However, histopathology of the mass was consistent with the diagnosis of aspergilloma. This patient was an otherwise healthy, elderly male with a well documented history of trauma followed by development of a corneal ulcer which was probably fungal in aetiology. The disease was neglected by the patient and over a period of time, the fungi could have infiltrated the anterior chamber which led to colonisation and formation of an aspergilloma. Subsequently, sudden or chronic hypotony following corneal perforation led to suprachoroidal and vitreous haemorrhage, pushing the intraocular fungal ball along with blood and uveal tissue through the cornea to the exterior. We propose this to be the most likely course of events as this explains the appearance of a large, tenacious, well circumscribed ball of hyphae over a short span of one week. On histopathology the hyphal ball was localised anterior to the posterior lens capsule with suprachoroidal and vitreous haemorrhage which further supported the diagnosis of an intraocular aspergilloma. However, the remote possibility of fungal colonisation over the prolapsed uveal tissue cannot be ruled out completely.

Fungal balls or mycetomas are formed by the colonisation of fungus in the existing usually diseased cavities. Although many fungi can cause fungal balls, most of them are caused by members of the genus Aspergillus, leading to formation of an aspergilloma. These fungal balls are usually localised within the walls of the cavity. Aspergillomas are commonly seen in the lung and paranasal sinuses.[1],[4] Ocular involvement may occur as endophthalmitis, and lid and orbital aspergilloma.[2],[5],[6],[7] In the eye, Aspergillus fumigatus has been most commonly isolated.[3],[5],[7] Aspergillus flavus, Aspergillus terreus and Aspergillus glaucus are other species implicated as the offending organisms.[2],[3]

The genus Aspergillus is the most common group of fungi in man's environment and is also a part of normal human conjunctival flora.[8] Miloshev et al[4] suggested that in hot, moist climates Aspergillus is probably a normal inhabitant of the nasal passages and may often become pathogenic. In the present case, concurrent sinus infection could not be demonstrated. There was no evidence of a systemic nidus of fungal infection. But the fact that the patient had a nonhealing corneal ulcer led us to speculate that the organism migrated through this relatively compromised site into the eye.

 
  References Top

1.
Seaton A, Seaton D, Leitch AG. Crofton and Douglas's Respiratory Diseases. 4th ed. Germany : Blackwell Science Ltd.; 1997. pp 448-75.  Back to cited text no. 1
    
2.
Krzystolik MG, Ciulla TA, Topping TM, Baker AS. Exogenous Aspergillus niger endophthalmitis in a patient with a filtering bleb. Retina 1997;17:461-62.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.
Weishaar PD, Flynn HW, Murray TG, Davis JL, Barr CC, Gross JG et al. Endogenous Aspergillus Endophthalmitis: Clinical features and treatment outcomes. Ophthalmology 1998;105:57-65.  Back to cited text no. 3
    
4.
Miloshev B, Davidson CM, Gentles JC. Aspergilloma of paranasal sinuses and orbit in northern Sudanese. Lancet 1966;1:746-50.  Back to cited text no. 4
    
5.
Harrell ER, Wolter JR, Gutow RF. Localized aspergilloma of the eyelid. Arch Ophthalmol 1966;76:322-24.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.
Chandra P, Ahluwalia BK, Chugh TD. Primary orbital aspergilloma. Br J Ophthalmol 1970;54:693-96.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.
Townes DE. Orbital aspergilloma. Surv Ophthalmol 1967;12:337-43.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.
Munro S. Ocular aspergillosis. Trans Ophthalmol Soc UK 1969;9:743-56.  Back to cited text no. 8
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]


This article has been cited by
1 Pinguecula masquerading as conjunctival melanoma
Suresh, K., Doctor, P.
Indian Journal of Ophthalmology. 2007; 55(1): 83-84
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2 Masquerade lesions of the orbit and adnexa
Pushker, N., Bajaj, M., Chaturvedi, A., Sen, S., Kashyap, S.
Indian Journal of Ophthalmology. 2006; 54(2): 139
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3 Prolapsed intraocular aspergilloma masquerading as malignant melanoma
Thomas, P.A., Geraldine, P.
Indian Journal of Ophthalmology. 2004; 52(2): 172-173
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