|Year : 2001 | Volume
| Issue : 1 | Page : 49-51
Panophthalmitis due to Rhizopus in an AIDS Patient: A clinicopathological study
Tapan K Samanta1, Jyotirmay Biswas1, Lingam Gopal1, Anand A R2, N Kumarasamy3, Suniti Solomon4
1 MS. Medical and Vision Research Foundation Chennai, India
2 MSc. Medical and Vision Research Foundation Chennai, India
3 MBBS,PhD. YRG Centre for AIDS Research and Education Chennai, India
4 MD. YRG Centre for AIDS Research and Education Chennai, India
Tapan K Samanta
MS. Medical and Vision Research Foundation Chennai, India
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Samanta TK, Biswas J, Gopal L, AnandA, Kumarasamy N, Solomon S. Panophthalmitis due to Rhizopus in an AIDS Patient: A clinicopathological study. Indian J Ophthalmol 2001;49:49-51
Human immunodeficiency virus (HIV) infection is increasing at an alarming rate in India. Various ocular manifestations have been described by us in earlier reports. [1,2] Panophthalmitis in AIDS patients is however rare.[3-6] Here we report the case of a young adult male, with unilateral panophthalmitis diagnosed as HIV-positive 5 years previously. He required evisceration, as the eye became painful and blind. Microbiological study of the eviscerated material revealed the fungus Rhizopus. We describe this rare case with a brief review of the literature.
| Case report|| |
A 31-year-old male presented complaining of sudden loss of vision in the right eye for one week, associated with pain, redness and swelling in that eye. He was diagnosed by his local ophthalmologist as having endophthalmitis in the right eye. There was no history of any eye surgery or trauma. He had been detected HIV-positive 5 years previously following multiple unprotected sexual exposures to commercial sex workers. The patient also gave a history of treatment with anti-tubercular drugs for a diagnosis of pulmonary tuberculosis for 6 months. There was no history of any other systemic illness.
On examination, visual acuity was no light perception (NLP) in the right eye and 6/5, N6 in the left eye. The right eye had complete ptosis and 5° exotropia. Ocular movements were free but associated with mild pain in the right eye. On slitlamp examination of the right eye, conjunctiva appeared diffusely congested and chemosed, with multiple Descemet's folds in cornea. Aqueous flare (++) and aqueous cells (+) were present. The pupil was mid-dilated and non-reacting to light; the lens showed early cataract. Fundus examination with an indirect ophthalmoscope revealed yellowish reflex [Figure - 1]. The disc could not be seen, but the retina was attached. A clinical diagnosis of panophthalmitis in the right eye was made. The left eye was normal. Clinically, an endogenous infection, possibly of fungal aetiology, was suspected.
On routine haemogram the total leukocyte count was 10,400/mm3. Differential count showed neutrophils 85%, eosinophils 1% and lymphocytes 14%. Erythrocyte sedimentation rate was 60 mm in the first hour. Random blood sugar was 82 mg/dl. Microscopic examination of urine showed 3-4 pus cells/HPF. VDRL and Treponema pallidum haemagglutination test were non-reactive. Chest x-ray was normal. Sputum examination did not show any acid-fast bacillus (AFB) in Ziehl Neelsen stain or fungus in potassium hydroxide and calcofluor white preparation.
Anterior chamber (AC) tap was done in the outpatient department under topical anaesthesia with aseptic precautions. AC fluid microscopy with potassium hydroxide and calcofluor white preparation did not show fungus. Gram stain showed plenty of polymorphonuclear cells, uveal pigment, mononuclear leukocytes with degenerated cellular material, and no bacteria. Acid-fast bacillus was not found in the Ziehl Neelsen stain. The aqueous aspirate was inoculated in blood agar, Brucella blood agar (BBA), Sabouraud's dextrose agar (SDA), brain-heart infusion broth (BHIB) and Lowenstein Jensen media. The cultures did not show any growth of fungus, bacteria or acid-fast bacillus. Systemic evaluation by our internist and AIDS care specialist revealed oesophageal candidiasis, but no other systemic abnormality.
The patient was given injection cefotaxime 1 gram twice daily and topical ciprofloxacin and tobramycin eye drops hourly. In view of the progressive worsening of ocular infection, and chances of spread to the central nervous system, and since the eye had NLP, urgent evisceration was suggested. Evisceration was done under general anaesthesia, with special barrier precautions as advised in an AIDS patient. A part of the eviscerated material was directly inoculated into BHIB and Robertson's cooked meat broth in the operating room. On histopathological examination of the eviscerated material, numerous fungal filaments were seen underneath the retinal pigment epithelium (RPE) [Figure - 2], with areas of haemorrhage and necrosis, and dense infiltration of inflammatory cells, predominantly polymorphonuclear leukocytes. Periodic acid Schiff stain showed broad aseptate irregularly branching fungal hyphal elements [Figure:2, inset] underneath the RPE. The cultures of the eviscerated material showed growth of fungus after 48 hours. The fungus was identified as Rhizopus using slide culture technique by lactophenol cotton blue preparation, showing characteristic sporangia and rhizoids [Figure - 3].
Microbiological investigations of the cerebrospinal fluid obtained by lumbar puncture (direct smear of potassium hydroxide and calcofluor stain, Gram stain, stain for AFB, bacterial and fungal cultures) were negative.
The socket of the enucleated eye was healthy in the follow-up visit after 3 weeks. The patient was found otherwise systemically healthy.
| Discussion|| |
Only few reports of panophthalmitis in AIDS cases exist. These patients were younger than the panophthalmitis cases without HIV3.The causative agents of panophthalmitis in AIDS patients include Toxoplasma gondii, atypical Mycobacteria and Staphylococcus aureus. Endogenous panophthalmitis caused by the fungus Rhizopus is not reported (Medline search).
In our case, the mode of presentation of sudden onset of visual loss without any history of trauma or surgery was suggestive of endogenous infection. Since the patient was HIV sero-positive, the possibility of opportunistic pathogens like fungus was strongly suspected. Initial microbiological investigations of the aqueous aspirate, however, was negative for fungus and only culture of eviscerated material was positive. Such negative aqueous aspirate study is also reported in endogenous fungal endophthalmitis by Weishaar et al. It may be attributed to the relatively localised nature of the fungus in the subretinal space, causing panophthalmitis through liberation of toxins and lytic enzymes.
The genus Rhizopus [bread mould] is a fungus in the order mucorales, class Zygomyecetes. The fungus, identified by its characteristic morphology, appears as broad ribbon-like, 10 to 20μ in diameter, non-septate hyphae with branches occurring at right angles. Differentiation of the genus Rhizopus from other agents of mucormycosis is done by microscopic examination for the presence and location of rhizoids, the presence of apophysis and the morphology of columella.
The present case is unique in several aspects. These include (a) association of unusual fungus that caused severe intraocular infection; (b) the rapid course of infection; and (c) apparent lack of systemic Rhizopus infection.
Rhizopus is known to be associated with orbital cellulitis and complications of diabetic ketoacidosis in HIV infection. However, panophthalmitis caused by this fungus in a case of nondiabetic HIV patient is unusual. The rapid course of the infection presumably was due to immunosuppression secondary to HIV infection. We could not, however, obtain a correlation with the immune status with CD4 and CD8 cell counts due to financial constraints. The patient had oesophageal candidiasis and pulmonary tuberculosis which indirectly indicates poor immune function. The apparent lack of systemic signs of Rhizopus infection, could be due to the sequestration of the organism in the subretinal space. Microorganisms like Mycobacterium tuberculosis and Nocardia are known to remain localised to the subretinal space though the reason for such sequestration still remains unclear.
Our case highlights that endogenous intraocular infection can occur due to the fungus Rhizopus in an AIDS patient.
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[Figure - 1], [Figure - 2], [Figure - 3]