A 64-year-old man presented with gradual painless decrease of vision and floaters in the right eye for 6 weeks. His history was notable for hepatocellular carcinoma requiring orthotopic liver transplant 2 years prior, and he remained on chronic immunosuppressive therapy including mycophenolate mofetil, tacrolimus, and prednisone. He was hospitalized 3 months prior to presentation for cavitary pneumonia, with bronchoalveolar lavage (BAL) cultures growing Nocardia farcinica and Aspergillus fumigatus. He was treated with voriconazole and trimethoprim-sulfamethoxazole (Bactrim), which was later switched to ciprofloxacin due to renal toxicity.
The patient appeared well-nourished and in no acute distress. Ophthalmic examination showed a visual acuity (VA) of 20/300 in the right eye and 20/25 in the left eye. Anterior segment exam OD revealed 3+ anterior chamber cell and 3+ vitreous cell and haze. Fundus examination of the right eye showed a yellow-white subretinal mass nasal to the optic nerve and extending to the mid-periphery (Fig. 1).
The differential diagnosis included infectious and autoimmune etiologies, as well as post-transplant, Epstein Barr virus (EBV)-associated lymphoproliferative disorder. The patient underwent a vitreous tap, which was unsuccessful at obtaining a vitreous specimen, followed by aspiration of anterior chamber (AC) fluid. Cultures of AC fluid grew no organisms and no PMNs. He was given an intravitreal injection of voriconazole and vancomycin. Intravitreal ceftazidime was held because the strain was resistant to cephalosporins. Amikacin was initially held for potential aminoglycoside toxicity. The patient was started on topical corticosteroids and cycloplegic eye drops.
The initial BAL tissue specimen and sputum culture later grew Nocardia farcinia that was susceptible to Bactrim, ciprofloxacin, linezolid, and amikacin. Due to issues with receiving Bactrim, the patient was given oral voriconazole and levofloxacin, as well as the first dose of intravitreal amikacin.
At follow-up, B-scan showed new nasal retinal traction in the right eye (Fig. 2). Given persistent vitritis and active-appearing subretinal lesion, intravitreal amikacin was given again. Over 4 weeks, four doses of 0.2 mg of intravitreal amikacin were administered into the vitreous overlying the abscess. Three months after initial presentation, the patient underwent pars plana vitrectomy and membrane peel. Because the abscess appeared inactive, retinotomy and debridement were deferred, and the dense overlying membrane was removed. Vitreous fluid aspirate from the surgery was negative for bacterial and fungal organisms. At post-operative week two, the patient showed improvement of vision to 20/60 and a decrease in the size of the subretinal abscess (Fig. 3). Cataract extraction with intraocular lens (IOL) was performed 7 months later with VA of 20/60 at post-op day zero. The patient had a VA of 20/100 at final follow-up, almost a year from initial presentation.