- Brief Report
- Open Access
Scedosporium apiospermum endopthalmitis treated early with intravitreous voriconazole results in recovery of vision
© The Author(s) 2012
- Received: 15 July 2011
- Accepted: 7 February 2012
- Published: 28 February 2012
The purpose of this study is to report a case of endogenous endopthalmitis caused by Scedosporium apiospermum with a favorable outcome and review previously reported cases, their treatment regimens and outcomes.
An 83-year-old man with diabetes mellitus, no other immunocompromising risk factors, and a history of S. apiospermum endopthalmitis in the left eye developed endopthalmitis in the right eye. Within 72 h of presentation, he was treated with a pars plana vitrectomy and intravitreal voriconozole.
Vitreous cultures confirmed S. apiospermum. The patient responded to treatment, with a favorable outcome and full recovery of vision.
Recognition of S. apiospermum endopthalmitis and appropriate early intervention with pars plana vitrectomy and intravitreal voriconozole can lead to a favorable outcome with restoration of visual acuity.
- Endogenous endopthalmitis
- Scedosporium apiospermum
Scedosporium apiospermum is an opportunistic fungus that can affect the eye, presenting as keratitis, chorioretinitis, or endophthalmitis, often with devastating consequences . Disseminated life-threatening disease and endogenous endophthalmitis are generally seen in immunocompromised patients; however, immunocompetent individuals can also be affected with exogenous endophthalmitis from trauma.
This species of Scedosporium, the anamorph (asexual state) of Pseudallescheria boydii, is a ubiquitous filamentous fungus, found in soil, sewage, and polluted water . The subclassification of this genetically heterogeneous species makes medical literature confusing. Synomorphs of S. apiospermum include Monosporium apiospermum, Monosporium sclerotiale, Indiella americana, Acremoniella lutzi, and Polycytella hominis . In addition, the number of cases may be underreported or misdiagnosed because it is clinically indistinguishable from “the great imitator” and more commonly occurring fungus, Asperigillus fumigatus [2, 3].
Review of additional reported cases of endogenous endopthalmitis caused by S. apiospermum not reviewed by Larocco et al.
Other sites of infection
McKelvie et al. 
Blood and vitreous
Intraocular AmpB, Foscarnet, Vanco (dx species postmortem)
Figueroa et al. 
Post-kidney transplant; on mycophenolate, tacrolimus, and corticosteroids
Vitrectomy, PO Vori
Larocco et al. 
Presumed sinusitis, sepsis 2/2, pseudomemebranous colitis
AmpB IVT and systemic, followed by itraconazole when dx of S. apiospermum was made
Musk et al. 
Lung transplant due to alpha1-anti-trypsin deficiency, on cyclosporine, azothioprine, and prednisolone
Vitreous and epididymis
PO, IVT, and topical Vori
Lung and skin nodules, epididymoorchitis
Poor vision, remains on voriconozole with no evidence of disease
Lung transplant for interstitial pneumonitis on high-dose steroids
PCR retinal biopsy, vitreous culture
Intravitreous Vori and AmpB; PO Vori
No recovery of vision, survived
Jain et al. 
Pre-B cell acute LL, neutropenia
Vori IVT and PO
Blood and lung
Enucleation, death from sepsis; NLP
Pre-B cell acute LL
IVT voriconozole, AmpB
Endopthalmitis stabilized; multiorgan system failure
Wegener’s granulomatosis; corticosteroids and cyclophosphamide
IVT AmpB, itraconazole
No visual recovery, CNS involvement
Chen et al. 
Post-lung transplant; immunosuppresive Rx
Vitrectomy, IV and IVT Vori
Enucleation; secondary scleritis; LP
PO Vori, IV AmpB, PO terbinafine, IVT Vori
Shankar et al. 
Anterior chamber wash and IVT Vori
Resolution of vitreous exudates
Ikewaki et al. 
DM; sub-Tenon’s triamcinolone injection
Topical and IVT irrigation with Vori
Improvement to baselineImprovement to baseline (0.02 to 0.5)
IV and IVT Vori
Stable at 20/40
An 83-year-old monocular male presented with complaints of new floaters in his right eye. His visual acuity was counting fingers, intraocular pressure was 8 mmHg with 3+ cells in his anterior chamber, and a dense vitritis. Ultrasound confirmed vitritis with an attached retina. The patient was seen by a referring ophthalmologist the day before with similar complaints of floaters with visual acuity of 20/40 due to nuclear sclerosis.
The patient had been no light perception in his left eye for over a year due to endogeneous endophthalmitis from a fungal lung lesion. At that time, both vitreous and lung biopsies grew out S. apiospermum. Other than diabetes, a thorough infectious disease work-up revealed no other immunocompromising risk factors. The lung lesions were unchanged after a course of treatment, and the patient’s family did not want further work-up such as a re-biopsy due to the patient’s age. The patient was prescribed a maintenance dose of voriconazole 200 mg PO QD, but he was noncompliant and stopped taking his medicine.
At the time of presentation to our clinic, the patient had symptoms in his right eye for less than 24 h. An intravitreal biopsy was performed in conjunction with intravitreal voriconazole (100 μg/0.1 ml). Vitreous biopsy at this time grew out S. aspiospermum. The patient was also started on intravenous voriconazole. After 48 h with no improvement, the patient was brought to the operating room for a 23-gauge pars plana vitrectomy and repeat intravitreal voriconazole (100 μg/0.1 ml) injection. There were no intraretinal lesions seen at the time of surgery, although the view was hazy. The patient did not receive any intravitreal or oral steroids. His inflammation subsided slowly over the course of 3 weeks with moxifloxacin and prednisolone acetate eye drops. One month after presentation, his visual acuity returned to 20/40.
S. apiospermum endophthalmitis presents with an aggressive clinical course, oftentimes requiring enucleation. Treatment is particularly challenging due to resistance to many antifungal agents. Here, we report a case of endogenous S. apiospermum endopthalmitis in a diabetic patient that responded favorably to voriconazole with full restoration of visual acuity. To our knowledge, this is the third reported case of successful treatment outcome for endogenous endophthalmitis due to this fungal species [5, 11]. Our case is unique in that voriconazole combined with early surgical intervention led to a favorable outcome.
Two cases of successful treatment outcomes for S. apiospermum endopthalmitis have previously been described. In 2007, Shankar et al. reported a case a case of endogenous endophthalmitis from an unknown source in a 61-year-old man with diabetes mellitus (DM). Anterior chamber biopsy was positive for S. apiospermum and the patient was treated with intravitreal amphotericin B and voriconazole with restoration of vision .
Two years later, another case of S. apiospermum endophthalmitis with a good outcome was published by Ikewaki et al. They described a 58-year-old man with DM who developed exogenous endopthalmitis following sub-Tenon’s injection with triamcinolone acetonide for treatment of macular edema. The patient was not diagnosed or treated until 5 months after the sub-Tenon’s injection, when a periocular abscess was drained with cultures revealing S. apiospermum. By this time, extensive vitritis with opacities, pale optic disc, periphlebitis, serous detachment of the macula, retinal hemorrhages, and a whitish subretinal peripheral mass were seen. Following a vitrectomy and irrigation with voriconazole, vision was restored .
To date, a few over 20 cases of endogenous endopthalmitis from S. apiospermum have been reported in the literature (reviewed in Larocco et al. and Table 1). The collection of cases, with a large proportion of systemically ill patients having a wide range of presentations, emphasizes the need to have adequate biopsy results. They also point out the importance of working collaboratively with an infectious disease and internal medicine team. Various antifungal agents have been administered intravitreously for treating fungal endophthalmitis. The most common agent, amphotericin B, is associated with retinal toxicity and resistance has emerged [15, 18]. Amphotericin B is generally ineffective against S. apiospermum and voriconazole, the second-generation derivative of fluconazole, is accepted as the treatment of choice for this pathogen. It is a broad-spectrum antifungal agent with high bioavailability, quick onset of action, and good ocular penetration .
The investigation of the pharmacokinetics of voriconazole indicates that the MIC90 (minimum inhibitory concentrations at which 90% of isolates of S. apiospermum are inhibited) can be attained in the vitreous and aqueous after oral administration [15, 19]. Oral dosing is 200 mg BID with or without a loading dose . Alternatively, it can be given twice a day IV with a loading dose of 6 mg/kg Q12 hours for 1 day, followed by 4 mg/kg BID. While animals studies report a intravitreal voriconazole dose of 100 μg to be effective and safe , 200 μg intravitreal injection has been used successfully in humans .
In summary, this is rare a case of endogenous fungal endophthalmitis due to S. apiospermum in which a history of prior infection in the other eye allowed appropriate early intervention, both pharmacologic and surgical, leading to a successful outcome. The patient was treated aggressively with intravitreal voriconazole, systemic voriconazole, and pars plana vitrectomy leading to a favorable outcome. Thus, it is reasonable to initiate early treatment with voriconazole when fungal endopthalmitis is suspected even prior to obtaining definitive culture results.
We would like to thank the Research for Prevention of Blindness for their support.
Conflict of interest
The authors have no proprietary interest related to this work.
- Cortez KJ, Roilides E, Quiroz-Telles F, Meletiadis J, Antachopoulos C, Knudsen T, Buchanan W, Milanovich J, Sutton DA, Fothergill A, Rinaldi MG, Shea YR, Zaoutis T, Kottilil S, Walsh TJ (2008) Infections caused by Scedosporium spp. Clin Microbiol Rev 21(1):157–197. doi:10.1128/CMR.00039-07PubMedPubMed CentralView ArticleGoogle Scholar
- McGuire TW, Bullock JD, Bullock JD Jr, Elder BL, Funkhouser JW (1991) Fungal endophthalmitis. An experimental study with a review of 17 human ocular cases. Arch Ophthalmol 109(9):1289–1296PubMedView ArticleGoogle Scholar
- Rippon JW (1981) Petriellidiosis: the great imitator. Clin Microbiol Newletter 3:57–58View ArticleGoogle Scholar
- Musk M, Chambers D, Chin W, Murray R, Gabbay E (2006) Successful treatment of disseminated scedosporium infection in 2 lung transplant recipients: review of the literature and recommendations for management. J Heart Lung Transplant 25(10):1268–1272. doi:10.1016/j.healun.2006.06.002PubMedView ArticleGoogle Scholar
- Shankar S, Biswas J, Gopal L, Bagyalakshmi R, Therese L, Borse NJ (2007) Anterior chamber exudative mass due to Scedosporium apiospermum in an immunocompetent individual. Indian J Ophthalmol 55(3):226–227PubMedView ArticleGoogle Scholar
- Nochez Y, Arsene S, Le Guellec C, Bastides F, Morange V, Chaumais MC, Pisella PJ (2008) Unusual pharmacokinetics of intravitreal and systemic voriconazole in a patient with Scedosporium apiospermum endophthalmitis. J Ocul Pharmacol Ther 24(1):87–90. doi:10.1089/jop.2007.0087PubMedView ArticleGoogle Scholar
- Chen FK, Chen SD, Tay-Kearney ML (2007) Intravitreal voriconazole for the treatment of endogenous endophthalmitis caused by Scedosporium apiospermum. Clin Experiment Ophthalmol 35(4):382–385. doi:10.1111/j.1442-9071.2007.01493.xPubMedView ArticleGoogle Scholar
- Sarvat B, Sarria JC (2007) Implantable cardioverter-defibrillator infection due to Scedosporium apiospermum. J Infect 55(4):e109–e113. doi:10.1016/j.jinf.2007.07.010PubMedView ArticleGoogle Scholar
- McKelvie PA, Wong EY, Chow LP, Hall AJ (2001) Scedosporium endophthalmitis: two fatal disseminated cases of Scedosporium infection presenting with endophthalmitis. Clin Experiment Ophthalmol 29(5):330–334PubMedView ArticleGoogle Scholar
- Orr PH, Safneck JR, Napier LB (1993) Monosporium apiospermum endophthalmitis in a patient without risk factors for infection. Can J Ophthalmol 28(4):187–190PubMedGoogle Scholar
- Ikewaki J, Imaizumi M, Nakamuro T, Motomura Y, Ohkusu K, Shinoda K, Nakatsuka K (2009) Peribulbar fungal abscess and endophthalmitis following posterior subtenon injection of triamcinolone acetonide. Acta Ophthalmol 87(1):102–104. doi:10.1111/j.1755-3768.2007.01166.xPubMedView ArticleGoogle Scholar
- Larocco A Jr, Barron JB (2005) Endogenous Scedosporium apiospermum endophthalmitis. Retina 25(8):1090–1093PubMedView ArticleGoogle Scholar
- Figueroa MS, Fortun J, Clement A, De Arevalo BF (2004) Endogenous endophthalmitis caused by Scedosporium apiospermum treated with voriconazole. Retina 24(2):319–320PubMedView ArticleGoogle Scholar
- Glassman MI, Henkind P, Alture-Werber E (1973) Monosporium apiospermum endophthalmitis. Am J Ophthalmol 76(5):821–824PubMedView ArticleGoogle Scholar
- Zarkovic A, Guest S (2007) Scedosporium apiospermum traumatic endophthalmitis successfully treated with voriconazole. Int Ophthalmol 27(6):391–394. doi:10.1007/s10792-007-9095-0PubMedView ArticleGoogle Scholar
- Nulens E, Eggink C, Rijs AJ, Wesseling P, Verweij PE (2003) Keratitis caused by Scedosporium apiospermum successfully treated with a cornea transplant and voriconazole. J Clin Microbiol 41(5):2261–2264PubMedPubMed CentralView ArticleGoogle Scholar
- Jain A, Egbert P, McCulley TJ, Blumenkranz MS, Moshfeghi DM (2007) Endogenous Scedosporium apiospermum endophthalmitis. Arch Ophthalmol 125(9):1286–1289. doi:10.1001/archopht.125.9.1286PubMedView ArticleGoogle Scholar
- Axelrod AJ, Peyman GA (1973) Intravitreal amphotericin B treatment of experimental fungal endophthalmitis. Am J Ophthalmol 76(4):584–588PubMedView ArticleGoogle Scholar
- Hariprasad SM, Mieler WF, Holz ER, Gao H, Kim JE, Chi J, Prince RA (2004) Determination of vitreous, aqueous, and plasma concentration of orally administered voriconazole in humans. Arch Ophthalmol 122(1):42–47. doi:10.1001/archopht.122.1.42PubMedView ArticleGoogle Scholar
- Gao H, Pennesi ME, Shah K, Qiao X, Hariprasad SM, Mieler WF, Wu SM, Holz ER (2004) Intravitreal voriconazole: an electroretinographic and histopathologic study. Arch Ophthalmol 122(11):1687–1692. doi:10.1001/archopht.122.11.1687PubMedView ArticleGoogle Scholar
This article is published under license to BioMed Central Ltd. Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.