Phaeohyphomycosis due to Scopulariopsis brumptii in a Hematopoietic Stem Cell Transplant (HSCT) recipient
We present a rare case of Scopulariopsis brumptii endophthalmitis and discuss therapeutic strategies including systemic and intraocular anti-fungal therapy, and surgical intervention. The combination of highly-resistant pathogen, unique sanctuary site, and vulnerable host makes this a challenging case.
We reviewed medical records of a patient who received HSCT for acute myelogenous leukemia and presented with acute right-sided eye pain and photophobia seven months post-transplant while on posaconazole prophylaxis.
Ophthalmological exam showed pan-uveitis and vitritis. Skin exam was normal. Labs revealed leukopenia of 0.5X 10(9)/mL and (1, 3) -ß-D-glucan of >500 pg/mL. CT of chest and sinuses was unremarkable. Patient received intravitreal amphotericin B followed by voriconazole thrice weekly and oral posaconazole. Vitreous aspirate was negative for bacterial, mycobacterial, and fungal cultures and broad-range PCR. Subsequently patient developed new pre-retinal lesions and posaconazole was switched to intravenous liposomal amphotericin B. Intravitreal amphotericin B deoxycholate was continued.
Vitrectomy was performed with cultures yielding Scopulariopsis brumptii. Susceptibility data demonstrated high minimal inhibitory concentrations (MICs) for posaconazole and voriconazole and low MICs for isavuconazole, amphotericin and echinocandins. He was treated with 2 weeks of local and systemic amphotericin B therapy before developing acute kidney injury. He was then transitioned to isavuconazole. Intraocular injections were discontinued after 6 weeks when (1, 3) -ß-D-glucan was 46 pg/mL and resolution of retinal lesions. Patient was kept on isavuconazole chronic suppression.
Scopulariopsis brumptii is known for resistance to many anti-fungal agents. Our case highlights the importance of vitrectomy and intraocular drug injection due to poor penetration from systemic therapy. With aggressive local and systemic therapy and surgery, our patient had good outcome.
Figure 1. Funduscopic examination revealing retinal lesions.
Figure 2. Scopulariopsis brumptii microscopic appearance.
D. M. Barth, None
O. Abu Saleh, None
P. Vijayvargiya, None
M. R. Sohail, None