Granulomatous meningoencephalitis and blindness associated with Mycobacterium tuberculosis complex infection in a senile female chimpanzee (Pan troglodytes).

A 40-year old female chimpanzee (Pan troglodytes) developed hyporexia, weight loss, followed by progressive and complete blindness. Tomography demonstrated an intracranial mass in the rostroventral brain involving the optic chiasm, with a presumptive diagnosis of neoplasm. However, histopathology revealed a granulomatous meningoencephalitis, and tissue samples tested positive for Mycobacterium tuberculosis.

Cerebrospinal fluid leak from lateral orbit during exenteration for mucormycosis.

We describe an elderly diabetic patient presenting with sudden onset right-sided proptosis and vision loss secondary to rhino-orbital mucormycosis and central retinal vascular occlusion. He underwent orbital exenteration that was complicated by intraoperative cerebrospinal fluid (CSF) leak from lateral orbital wall. The leak was surgically repaired and the patient recovered well. We postulate the cause of the CSF leak to be twofold: necrotic periorbital tissue due to mucormycosis rendering the thin bones susceptible to damage and second, intraoperative manipulation and dissection at the orbital apex with monopolar cautery and instruments. We describe measures taken to successfully repair the CSF leak and the possible precautions that can be taken to avoid it.

Invasive rhino-orbital-cerebral aspergillosis in an immunocompetent patient.

INTRODUCTION: Rhino-orbital-aspergillosis (ROA) is a rare but serious disease in immunocompetent patients. Diagnosis is often delayed due to the absence of specific clinical symptoms. We describe the case of a patient who presented initially with ROA which spread progressively to the right ethmoid-sphenoid sinuses and then to the brain. OBSERVATION: A 61-year-old patient with a history of well-controlled diabetes presented with a sudden severe decrease in right visual acuity. Cerebral MRI showed the presence of an infiltrate in the right orbital apex extending to the homolateral cavernous sinus without any cerebral involvement. A diagnosis of right orbital myositis was made and corticosteroid therapy was started. His symptoms worsened progressively leading to quasi-blindness. A new MRI showed the development of right sphenoid-ethmoid osteolytic lesions. A fungal aetiology was suspected and tests for fungal biomarkers found a ß-(1-3)-D-glucan level of 99pg/ml but negative galactomannan. An ethmoid biopsy was performed for histological and mycological investigations, including the detection of Aspergillus DNA by qPCR. qPCR was positive and culture resulted in the isolation of multi-sensitive Aspergillus fumigatus. Treatment was initiated with voriconazole. Due to persistence of blindness and the appearance of a lesion extending to the right frontal lobe, surgical excision was performed followed by antifungal treatment for a total duration of 1year. The patient is currently stable, but has persistence of blindness in the right eye. CONCLUSION: Invasive ROA is a rare but serious disease in immunocompetent patients which should be evoked in the differential diagnosis of a tumour or vasculitis. Early diagnosis is essential for optimal management.

Ophtalmoplegia complicating sino-orbital mucormycosis.

PURPOSE: To report a case of complete ophthalmoplegia and blindness in sino-orbital mucormycosis. CASE REPORT: A 68-year-old woman with history of diabetes and breast cancer presented with sudden onset of fever, orbital pain and blindness in the right eye. The patient was found to have no light perception, complete ophthalmoplegia, chemosis, corneal ulcer and optic nerve atrophy. In rhinologic examination, necrosis was noticed. Brain and orbit magnetic resonance imaging showed diffuse sinusitis with orbital involvement. The result of the clinical examination was reported as sino-orbitalmucormycosis. The diagnosis was confirmed by pathological specimens. The patient underwent extensive surgical debridement and systemic antifungal treatment. Despite treatment, visual acuity did not recover. CONCLUSION: The sino-orbital form of mucormycosis is a rare and insidious fungal infection. Ocular findings may range from orbital pain to ophtalmoplegia and blindness such as in our case. Black scar tissues seen on the nasal mucosa are pathognomonic. Delay in treatment due to late presentation and complications were major determinants in ocular prognosis and survival outcome.

Concurrent intramedullary spinal cord and multiple intracranial tuberculomas with tuberculous optic neuritis: A rare case report.

Tuberculosis (TB) remains a worldwide burden, with a large majority of new active TB cases occurring in underdeveloped and developing countries. Tuberculous meningitis (TBM) is one of the common infections of central nervous system. Other manifestations include intracranial tuberculoma, tubercular brain abscess, spinal tuberculoma, and granulomatous arachnoiditis. Visual impairment in TBM may be due to optic neuritis, optochiasmatic arachnoiditis (OCA), tuberculoma in the chiasmatic region or in the optic pathways, chorioretinitis, secondary to hydrocephalus and increased intracranial pressure, and finally due to ethambutol toxicity. We report a case of young girl with concurrent spinal cord intramedullary tuberculoma and multiple intracranial tuberculomas with TBM and bilateral visual impairment due to tuberculous optic neuritis.

Elimination of blinding trachoma in China.

OBJECTIVE: To present the change in the prevalence of blindness caused by trachoma between 1987 and 2006 by secondary data analysis based on two China National Sample Surveys on Disability (CNSSD). METHODS: Secondary data analysis was performed on two China National Sample Surveys on Disability (CNSSD), which were national representative household surveys conducted in 1987 and 2006. The prevalence of blindness caused by trachoma was estimated by 10-year age group. In addition, the proportion of various causes of blindness was evaluated. The geographical distribution of blindness caused by trachoma both in 1987 and 2006 was analyzed in order to visualize the hot spots of blinding trachoma in China. RESULTS: The prevalence of blindness caused by trachoma in China decreased from 51.5/100,000 in 1987 to 17.6/100,000 in 2006. In addition, the proportion of blindness attributed to trachoma also decreased from 10.1% (1987) to 0.9% (2006). Moreover, the prevalence of blindness caused by trachoma was over 200/100,000 in 2.2% of sampled counties in 2006 as compared to 8.6% in 1987. The hot spots of blinding trachoma were shown to be limited to underdeveloped mountain areas in Hubei and Guizhou provinces. CONCLUSION: Although blinding trachoma is no longer the leading cause of blindness in China since the 2000's, the prevalence of trachoma should still be monitored in some underdeveloped mountain areas. Therefore, health organization must continue to fight against blinding trachoma in underdeveloped areas.

Endocarditis and monocular blindness.

A man aged 77 years with postrenal transplant lymphoproliferative disease was admitted with high fever, elevated inflammatory markers and a heart murmur. Blood cultures grew Enterococcus faecalis and he was found to have mitral valve endocarditis on echocardiogram and subsequently started on appropriate antibiotics. 5 days into treatment, he developed ocular symptoms and 3 days later, he had irreversible monocular visual loss. He was seen by the ophthalmology team who diagnosed endogenous endopthalmitis secondary to bacteraemic spread from his endocarditis. Despite treatment with intravitreal antibiotics and prolonged systemic antibiotics, his sight did not recover. Although septic emboli are common in endocarditis, endogenous endophthalmitis is rarely reported and frequently results in visual loss. Early treatment confers an improved prognosis.

Acute vision loss in post-partum period as presenting symptom of HIV-associated cryptococcal meningitis-an unusual case report.

BACKGROUND: Acute vision loss in the post-partum period can occur due to many reasons. Eclampsia, posterior reversible encephalopathy syndrome (PRES), pituitary apoplexy, and central serous retinopathy are some of the important causes. Cryptococcal meningitis as a cause of acute vision loss in the post-partum period has not been mentioned in literature. CASE PRESENTATION: A 25-year-old female presented to us with acute bilateral complete vision loss in the post-partum period. Her serum was tested positive for HIV antibodies. Cerebrospinal fluid (CSF) examination revealed cryptococcal meningitis. She was started on amphotericin B, antiretroviral drugs, and steroids. Though symptoms of meningitis resolved after treatment no significant improvement in vision was observed at 3 months. CONCLUSIONS: Cryptococcal meningitis may be considered as one of the causes of acute vision loss in pregnant/post-partum females with human immunodeficiency virus (HIV) positivity.

Candida albicans osteomyelitis as a cause of chest pain and visual loss.

Candida albicans osteomyelitis is a rare disease that occurs in immunocompromised individuals, sometimes with a late diagnosis related to the mismatch between symptoms and candidemia. This case refers to a 36-year-old male patient with a history of oesophageal surgery for achalasia with multiple subsequent surgeries and hospitalisation in the intensive care unit for oesophageal fistula complication. Four months after discharge, the patient was admitted to the infectious diseases department with pain in the 10th-12th left ribs, swelling of the 4th-6th costal cartilage and decreased visual acuity. An MRI study showed thickening and diffuse enhancement, with no defined borders in the cartilage and ribs, compatible with infection. After performing a CT-guided bone biopsy, isolated C. albicans sensitive to antifungal agents was detected. The patient started therapy with liposomal amphotericin B and maintenance fluconazole for 6 months and showed clinical and radiological improvement within this time.

Pathogenesis of progressive scarring trachoma in Ethiopia and Tanzania and its implications for disease control: two cohort studies.

BACKGROUND: Trachoma causes blindness through a conjunctival scarring process initiated by ocular Chlamydia trachomatis infection; however, the rates, drivers and pathophysiological determinants are poorly understood. We investigated progressive scarring and its relationship to conjunctival infection, inflammation and transcript levels of cytokines and fibrogenic factors. METHODOLOGY/PRINCIPAL FINDINGS: We recruited two cohorts, one each in Ethiopia and Tanzania, of individuals with established trachomatous conjunctival scarring. They were followed six-monthly for two years, with clinical examinations and conjunctival swab sample collection. Progressive scarring cases were identified by comparing baseline and two-year photographs, and compared to individuals without progression. Samples were tested for C. trachomatis by PCR and transcript levels of S100A7, IL1B, IL13, IL17A, CXCL5, CTGF, SPARCL1, CEACAM5, MMP7, MMP9 and CD83 were estimated by quantitative RT-PCR. Progressive scarring was found in 135/585 (23.1%) of Ethiopian participants and 173/577 (30.0%) of Tanzanian participants. There was a strong relationship between progressive scarring and increasing inflammatory episodes (Ethiopia: OR 5.93, 95%CI 3.31-10.6, p<0.0001. Tanzania: OR 5.76, 95%CI 2.60-12.7, p<0.0001). No episodes of C. trachomatis infection were detected in the Ethiopian cohort and only 5 episodes in the Tanzanian cohort. Clinical inflammation, but not scarring progression, was associated with increased expression of S100A7, IL1B, IL17A, CXCL5, CTGF, CEACAM5, MMP7, CD83 and reduced SPARCL1. CONCLUSIONS/SIGNIFICANCE: Scarring progressed in the absence of detectable C. trachomatis, which raises uncertainty about the primary drivers of late-stage trachoma. Chronic conjunctival inflammation appears to be central and is associated with enriched expression of pro-inflammatory factors and altered expression of extracellular matrix regulators. Host determinants of scarring progression appear more complex and subtle than the features of inflammation. Overall this indicates a potential role for anti-inflammatory interventions to interrupt progression and the need for trichiasis disease surveillance and surgery long after chlamydial infection has been controlled at community level.

Sudden loss of vision in an Acute Medical Unit.

We present a case report of young man with Type 1 diabetes who developed acute visual loss after initially presenting with diabetic ketoacidosis. The diagnosis of invasive paranasal sinusoidal aspergillosis was made following CT and biopsy. Although uncommon, visual loss is a recognised complication of disseminated aspergillosis and is more likely in immune-compromised patients and those with diabetes. Early investigation with appropriate sinus imaging and involvement of the Ear Nose and Throat team in recommended when patients with diabetes develop acute visual loss in the context of a non-specific infective illness.

Fungal ball within Onodi cell mucocele causing visual loss.

The Onodi cell is a pneumatized posterior ethmoid cell located laterally and superiorly to the sphenoid sinus and closely related to the optic nerve. A mucocele is a benign, expansile, cystlike lesion of the paranasal sinuses that is filled with mucoid secretion. Therefore, optic neuropathy caused by an infected mucocele in an Onodi cell is uncommon. Furthermore, fungal infection superimposed on an Onodi cell mucocele is extremely rare and has not been reported previously. Here, we describe the first case of fungal ball within Onodi cell mucocele causing visual loss, which was completely removed via transnasal endoscopic approach.

Fungal endophthalmitis associated with compounded products.

Fungal endophthalmitis is a rare but serious infection. In March 2012, several cases of probable and laboratory-confirmed fungal endophthalmitis occurring after invasive ocular procedures were reported nationwide. We identified 47 cases in 9 states: 21 patients had been exposed to the intraocular dye Brilliant Blue G (BBG) during retinal surgery, and the other 26 had received an intravitreal injection containing triamcinolone acetonide. Both drugs were produced by Franck's Compounding Lab (Ocala, FL, USA). Fusarium incarnatum-equiseti species complex mold was identified in specimens from BBG-exposed case-patients and an unopened BBG vial. Bipolaris hawaiiensis mold was identified in specimens from triamcinolone-exposed case-patients. Exposure to either product was the only factor associated with case status. Of 40 case-patients for whom data were available, 39 (98%) lost vision. These concurrent outbreaks, associated with 1 compounding pharmacy, resulted in a product recall. Ensuring safety and integrity of compounded medications is critical for preventing further outbreaks associated with compounded products.

Cavernous sinus thrombosis as a result of a fungal infection: a case report.

Cavernous sinus thrombosis (CST) is a rare disease with the potential for significant morbidity and even death. Rapid diagnosis and aggressive medical and surgical management are imperative for patients with CST. The cause may be aseptic or infectious. When the cause is infectious in nature, it is most commonly from a bacterial origin. However, we present the case of a 57-year-old man with a fungally related CST that ultimately led to his death.

Ocular complications of cryptococcal meningitis in patients with HIV: report of two cases and review of the literature.

AIDS-related cryptococcal meningitis can result in significant vision loss, but the risk factors, prognostic features, and optimal management of patients with ocular complications is unknown. We present 2 cases of blindness associated with cryptococcal meningitis and review the literature for associated cases. Twenty-six additional cases of vision deterioration or loss as a result of HIV-associated cryptococcal meningitis were reviewed. Irreversible and complete loss of vision occurred in 14 patients (50%). Permanent vision loss was more likely to occur in patients with ocular symptoms and neurologic signs at presentation. Nearly all patients with permanent visual loss experienced blindness within the first week after hospital admission. Visual complications are not uncommon in cryptococcal meningitis, and once vision loss occurs, it is often irreversible regardless of control of infection or intracranial pressure. Visual complaints in cryptococcal meningitis should be considered a potentially poor prognostic sign.

Avastin doesn't blind people, people blind people.

PURPOSE: To review the appropriate preparation of bevacizumab for intravitreal injection by compounding pharmacies with specific recommendations designed to prevent microbial contamination. DESIGN: Perspective. METHODS: A review and discussion of compounding issues with supporting literature, clinical experience, illustrations, and expert opinion. RESULTS: Closer examination of the events surrounding the recent clusters of infectious endophthalmitis cases occurring after the intravitreal injection of bevacizumab suggest that the vision loss is not the result of the drug or the injection technique, but rather of the compounding procedures used to prepare the syringes containing the bevacizumab. Noncompliance with recognized standards and poor aseptic technique are the most likely causes of these outbreaks. The key to preventing these catastrophic occurrences depends on the implementation of and strict adherence to United States Pharmacopoeia Chapter 797 requirements. CONCLUSIONS: Recommendations arising from a root cause analysis of infectious endophthalmitis outbreaks should focus on the procedures used by pharmacies to compound bevacizumab. Microbial contamination of bevacizumab-containing syringes prepared from the same vial of drug can be avoided by using a single vial of bevacizumab for each eye or by following strict adherence to United States Pharmacopoeia Chapter 797 requirements when compounding a single vial of bevacizumab into multiple syringes.

Mycobacterium ulcerans infection (Buruli ulcer) on the face: a comparative analysis of 13 clinically suspected cases from the Democratic Republic of Congo.

We report our experience in managing 13 consecutive clinically suspected cases of Buruli ulcer on the face treated at the hospital of the Institut Médical Evangélique at Kimpese, Democratic Republic of Congo diagnosed during 2003-2007. During specific antibiotherapy, facial edema diminished, thus minimizing the subsequent extent of surgery and severe disfigurations. The following complications were observed: 1) lagophthalmos from scarring in four patients and associated ectropion in three of them; 2) blindness in one eye in one patient; 3) disfiguring exposure of teeth and gums resulting from excision of the left labial commissure that affected speech, drinking, and eating in one patient; and 4) dissemination of Mycobacterium ulcerans infection in three patients. Our study highlights the importance of this clinical presentation of Buruli ulcer, and the need for health workers in disease-endemic areas to be aware of the special challenges management of Buruli ulcer on the face presents.

Cryptococcus gattii infection in a Spanish pet ferret (Mustela putorius furo) and asymptomatic carriage in ferrets and humans from its environment.

A domestic ferret (Mustela putorius furo) was presented with lymphadenopathy and acute bilateral blindness. Cytologic evaluation and biopsy of an affected lymph node revealed pyogranulomatous lymphadenitis with intralesional yeast consistent with Cryptococcus sp. Subsequent studies demonstrated Cryptococcus gattii serotype B VGI/AFLP4 as the causative agent. The ferret was treated with fluconazole and prednisone. After one month of therapy, an improvement of the clinical symptoms was detected although blindness persisted. Seven months after presentation, the disease progressed to a severe neurologic condition, and it was euthanized. Postmortem exam revealed disseminated cryptococcosis with prominent neurologic involvement. Nasal swabs of other ferrets and humans from the same household revealed that two ferrets and two humans to be asymptomatic carriers of the same strain of cryptococcus as the necropsied ferret. These findings stress the importance of veterinary diagnostic work with pets and epidemiological investigations for disease prevention in them and in their owners.

Bilateral Klebsiella pneumoniae (K1 serotype) endogenous endophthalmitis as the presenting sign of disseminated infection.

The authors report a rare presentation of bilateral Klebsiella pneumoniae endophthalmitis in an ambulatory patient without other known medical conditions. A 51-year-old Chinese woman presented with severe bilateral reduction in vision, photophobia, pain, and eyelid swelling. Hospital admission and evaluation revealed vitreous, blood, and urine cultures positive for K. pneumoniae (K1 serotype). Additional work-up revealed endocarditis, multiple liver abscesses, brain abscesses, and left lobar pneumonia. The patient underwent multiple bilateral intravitreal antibiotic injections. Ultimate visual acuity was no light perception in both eyes. K. pneumoniae endogenous endophthalmitis is a severe but potentially subclinical disease. Early diagnosis requires a high index of suspicion and recognition of risk factors including Asian ancestry and other sources of systemic infection including, most commonly, liver abscess.