双眼内源性真菌性眼内炎1例

A case report of endogenous fungal endophthalmitis of both eyes

32岁女性,因“右眼视力下降伴黑影飘动10天”就诊。患者平素贫血病史,血红蛋白71.0 g/L,否认全身其他疾病史。最佳矫正视力:右眼0.05,左眼1.0,右眼结膜轻度充血,前房Tyn(+++),前房积脓约1mm,玻璃体中度混浊,眼底模糊见视网膜平伏。右眼光学相干层析成像(OCT)见黄斑颞侧视网膜前局部增殖膜,下方信号遮挡,荧光素眼底血管造影(FFA)显示右眼视网膜血管后期荧光稍渗漏。初步诊断为右眼葡萄膜炎,予局部糖皮质激素治疗后症状好转。1个月余后患者因双眼视力下降并持续加重复诊,右眼视力降至FC/BE,左眼降至FC/50 cm,右眼玻璃体混浊,眼底窥不清,左眼Tyn(+),前房积脓约0.5 mm,玻璃体中度混浊,眼底模糊见视盘及黄斑间疑似黄白色病灶。为明确病因对患者进行了右眼玻璃体切除联合视网膜前膜剥除治疗,留取的玻璃体原液进行细菌、真菌涂片及培养,同时进行宏基因检测。宏基因检测结果为白色念珠菌(+),并经进一步G试验得到证实,涂片及培养结果为阴性。修正诊断为双眼内源性真菌性眼内炎(EFE),检查发现患者患有霉菌性阴道炎。对患者进行了双眼玻璃体腔注射伏立康唑联合全身伏立康唑治疗,后因左眼病情无明显好转予以左眼玻璃体切除联合视网膜前膜剥除治疗。经治疗后,患者双眼症状好转,视力改善,随访至今无复发。讨论体会:EFE早期易被误诊为葡萄膜炎,尤其是无基础疾病的患者,需提高对该病的认知,仔细询问病史,尽早抗真菌治疗,必要时联合玻璃体切除手术。

The patient was a 32-year-old woman who presented with“right eye vision loss with floating dark shadow for 10 days”.The patient had a history of anemia,a hemoglobin of 71.0g/L,and no history of other systemic diseases.The best corrected visual acuity was 0.05 and 1.0 in the right(OD)and left eye(OS),respectively.In the right eye,the conjunctival was mildly congested with significant anterior chamber reaction(Tyndall(+++))and 1mm hypopyon.The vitreous was moderately cloudy and the fundus examination revealed a blurred view of flat retina.Optical coherence tomography(OCT)in the right eye showed a localized proliferative epiretinal membrane in the temporal macula,and the signal below is obscured.Fluorescein fundus angiography showed slight leakage of fluorescence in the late phase from retinal vessels in the right eye.The patient was initially diagnosed with right uveitis,which improved after local glucocorticoid therapy.More than 1 month later,the patient returned to the doctor due to continued and worsening vision loss in both eyes.The visual acuity decreased to FC/BE(OD)and FC/50cm(OS).The fundus was indistinct due to vitreous opacity in the right eye.Tyndall was positive with a 0.5 mm hypopyon and moderately cloudy vitreous body in the left eye.The fundus was blurred and a suspected yellowish-white lesion was observed between the optic disc and macula in this eye.To determine the cause,the patient was treated with vitrectomy combined with epiretinal membrane stripping on right eye.The vitreous obtained during the operation was smeared and cultured for bacteria and fungi.At the same time,the vitreous was sent for metagenomic next-generation sequencing,which showed Candida albicans(+).It was confirmed by further G-test,even though the smear and culture results were negative.The revised diagnosis was bilateral endogenous fungal endophthalmitis(EFE),and examination revealed that the patient had fungal vaginitis.The patient was immediately treated with bilateral intravitreal injection of voriconazole combined with systemic voriconazole.After that,vitrectomy combined with epiretinal membrane peeling was performed in the left eye due to no significant improvement.Thereafter,the patient’s binocular symptoms improved,visual acuity increased,and there has being no recurrence so far.Discussion and experience:Endogenous fungal endophthalmitis is easily misdiagnosed as uveitis in the early stage,especially in patients with no underlying disease.It is necessary to improve the awareness of this disease,carefully inquire about patients’history,initiate antifungal treatment as soon as possible,and consider vitrectomy if necessary.