Anidulafungin versus fluconazole in the treatment of Candida albicans chorioretinitis.

BACKGROUND: Candida albicans chorioretinitis is the most common cause of endogenous fungal endophthalmitis. Echinocandins are recommended as first-line therapy in the treatment of invasive candidiasis (IC), but in clinically stable patients with IC and endophthalmitis caused by Candida species susceptible to azole compounds these are the first-line treatment due to their better intraocular penetration. CASE REPORT: A 42-year-old woman admitted to hospital for duodenal perforation after gastrointestinal surgery and treated with broad-spectrum antibiotics developed C. albicans candidemia. According to protocol, an antifungal treatment with anidulafungin was given. The patient presented no visual symptoms but on routinary ophthalmoscopic examination multiple bilateral chorioretinal lesions were observed. Systemic therapy was changed to fluconazole, with good systemic and ocular results. CONCLUSIONS: Azole compounds are the first-line therapy for endophthalmitis associated with candidemia. However, clinical guidelines often propose echinocandins as the first option for IC. In some cases, C. albicans chorioretinitis will require a change in the systemic treatment to assure better intraocular penetration. According to the current evidence and our own experience, routine funduscopy is not necessary in all IC patients. However, we do recommend fundus examination in patients with visual symptoms or those unable to report them (paediatric patients and patients with an altered level of consciousness), and in those who are being treated with echinocandins in monotherapy.

Measuring Choroid Thickness as a Marker of Systemic Inflammation in Patients With Ankylosing Spondylitis.

BACKGROUND AND OBJECTIVE: Ankylosing spondylitis (AS) is an inflammatory disease, and choroidal thickness (CT) has been proposed and evaluated as a potential marker of systemic inflammation associated with AS and other inflammatory diseases. This study compared CT measurements taken from patients with severe AS disease activity without eye inflammation with those taken from healthy subjects. METHODS: This cross-sectional, multicenter study compared CT in 44 patients with high AS disease activity, and no history of eye inflammation with CT in 44 matched healthy subjects aged between 18 and 65 years. In the AS group, the correlation between CT and C-reactive protein, human leukocyte antigen (HLA) B27 positivity, disease duration, and disease activity was calculated. RESULTS: Mean CT values of patients with AS were significantly higher in the right eye, the left eye, and the thickest choroid eye. The right eye mean CT was 338.3 ± 82.8 µm among patients with AS and 290.5 ± 71.2 µm among healthy subjects (p = 0.005). The left eye mean CT was 339.5 ± 84.7 µm for patients with AS and 298.4 ± 68.9 µm for healthy subjects (P = 0.015). The thickest choroid eye CT was 358.4 ± 82.1 µm among patients with AS and 314.1 ± 65.2 µm among healthy subjects (P = 0.006). We did not find a significant correlation between CT and disease activity, C-reactive protein, human leukocyte antigen B27 positivity, or disease duration. CONCLUSIONS: Patients with active AS but without a history of eye inflammation had a thicker choroid than healthy subjects. This finding suggests that CT is a marker of systemic inflammation in patients with inflammatory disease, regardless of known eye symptoms.

Inflammatory Relapses after Immunosuppressive Drug Discontinuation in Uveitis Patients: A Survival Analysis.

Purpose: To estimate the incidence rate (IR) and identify risk factors associated to inflammatory relapse after immunosuppressive drug (ISD) discontinuation in noninfectious uveitis patients.Methods: Multicenter longitudinal retrospective study, including patients from four uveitis clinics followed-up until December 2018. Hazard ratios for different variables were estimated using multivariable Cox models.Results: 32 patients (34 episodes of ISD discontinuation) were analyzed (median and maximum follow-up time: 2.4 and 19.2 years, respectively). Fourteen patients presented at least one relapse: anterior (8 patients), intermediate (5) and posterior (8). IR (95% confidence interval) of the first relapse was 14.3 (8.6-23.8) episodes per 100 patient-years (median survival time: 4.8 years). Early use of ISDs, panuveitis, and higher oral corticosteroid dosage at discontinuation were associated with higher hazards of relapse in multivariable analysis.Conclusions: Relapse is a frequent and early event after ISD discontinuation. Identifying relapse risk factors could support the physician's decision regarding ISD discontinuation.

Loiasis in sub-Saharan migrants living in Spain with emphasis of cases from Equatorial Guinea.

BACKGROUND: Loiasis is an uncommon and poorly understood parasitic disease outside endemic areas of Africa. The aim of this study was to describe the clinical and biological patterns and treatment of imported loiasis by sub-Saharan migrants diagnosed in Madrid, Spain. METHODS: A retrospective study was conducted with sub-Saharan immigrants seen at the Tropical Medicine Unit of the Carlos III Hospital in Madrid, Spain, a reference center, over 19 years. Categorical variables were expressed as frequency counts and percentages. Continuous variables were expressed as the mean and standard deviation (SD) or median and interquartile range (IQR: Q3-Q1). Chi-square tests were used to assess the association between categorical variables. The measured outcomes were expressed as the odds ratio (OR) with a 95% confidential interval. Continuous variables were compared by Student's t-tests or Mann-Whitney U tests. Binary logistic regression models were used. P <  0.05 was considered a statistically significant difference. RESULTS: One hundred thirty-one migrants from tropical and subtropical areas with loiasis were identified. Forty-nine patients were male (37.4%). The migrants' mean age (±SD) was 42.3 ± 17.3 years, and 124 (94.7%) were from Equatorial Guinea. The median time (IQR) between arrival in Spain and the first consultation was 2 (1-7) months. One hundred fifteen migrants had eosinophilia, and one hundred thirteen had hyper-IgE syndrome. Fifty-seven patients had pruritus (43.5%), and thirty patients had Calabar swelling (22.9%). Seventy-three patients had coinfections with other filarial nematodes (54.2%), and 58 migrants had only Loa loa infections (45.8%). One hundred two patients (77.9%) were treated; 45.1% (46/102) patients were treated with one drug, and 54.9% (56/102) patients were treated with combined therapy. Adverse reactions were described in 14 (10.7%) migrants. CONCLUSIONS: Our patients presented early clinical manifestations and few atypical features. Thus, physicians should systematically consider loiasis in migrants with a typical presentation. However, considering that 72.5% of the patients had only positive microfilaremia without any symptoms, we suggest searching for microfilaremia in every migrant from endemic countries for loiasis presenting with eosinophilia.

Choroidal Thickness Is a Biomarker Associated With Response to Treatment in Ankylosing Spondylitis.

OBJECTIVE: Choroidal thickness (CT) has been evaluated as a marker of systemic inflammation in ankylosing spondylitis (AS). This study evaluates the CT of AS patients before and after 6 months of biological treatment. METHODS: This longitudinal multicenter study evaluated CT in 44 AS patients. The correlations between CT and C-reactive protein (CRP) with disease activity indices were calculated. The concordance between CT and CRP was determined. We assessed factors associated with response to treatment. Clinically important improvement was defined as a decrease in Ankylosing Spondylitis Disease Activity Score of 1.1 points or greater. RESULTS: Forty-four eyes in patients aged 18 to 65 years were included. Mean CT values were significantly higher at baseline than after 6 months of treatment (baseline: 355.28 ± 80.46 µm; 6 months: 341.26 ± 81.06 µm; p < 0.001). There was a 95% concordance between CT and CRP at baseline and 6 months. Clinically important improvement was associated with lower baseline CT and age as independent factors (odds ratios, 0.97 [95% confidence interval, 0.91-0.93; p = 0.009] and 0.81 [95% confidence interval, 0.7-0.95; p = 0.005]), with baseline CT of less than 374 µm (sensitivity 78%, specificity 78%, area under the curve 0.70, likelihood ratio 3.6). CONCLUSIONS: Choroidal thickness decreased significantly after 6 months of biological treatment in all treatment groups. Choroidal thickness and CRP had a 95% concordance. A high CT was associated with a risk of biological treatment failure. Choroidal thickness can be considered a useful biomarker of inflammation and a factor associated with response to treatment in AS.

Case report: Bilateral uveitis and papillitis secondary to treatment with pembrolizumab.

Pembrolizumab is a programmed cell death protein 1 (PD-1) monoclonal antibody used in the treatment of metastatic melanomas. Severe ocular complications appear in less than 1% of the patients and require early treatment. We present the case of a patient diagnosed with a BRAF mutated metastatic melanoma. Ocular pain and a blurred vision appeared after treatment and the patient visited the ophthalmology emergency room, where he was diagnosed with acute anterior uveitis (AAU), synechiae, and bilateral papillitis. The patient was treated with topical corticosteroids, prednisone, and mydriatics, which immediately improved the patient's status. Therefore, when an ocular inflammatory disease exists, immune checkpoint inhibitor treatments must be ruled out as possible causes.

Dermatological manifestations in onchocerciasis: A retrospective study of 400 imported cases / Manifestaciones dermatológicas en oncocercosis: estudio retrospectivo de 400 casos importados

INTRODUCTION: Onchocerciasis is caused by Onchocerca volvulus and mainly leads to pruritus and skin and visual disorders, including blindness. Seventeen million people are infected in 38 countries; 31 of these are in sub-Saharan Africa, six in Latin America and one on the Arabian Peninsula. More than 99% of cases occur in sub-Saharan Africa where 120 million people are at risk of infection. Eye disorders have been well-documented; however, skin disorders have not been described accurately. The objective of our study was to describe the epidemiology, main skin manifestations and treatment of imported onchocerciasis. MATERIAL AND METHODS: A retrospective study was thus conducted by analysing the main demographic, clinical and treatment data regarding a cohort of 400 patients attending a reference clinical unit over a 17-year period. RESULTS: Most patients were female (55%) with mean age 37.5 ± 16.7 years. All the migrants came from sub-Saharan countries. The most frequently occurring dermatological symptom was pruritus. Ivermectin had been used as first-line therapy and adverse reactions had been described in 11 patients (3.2%). CONCLUSIONS: The results indicate the fact that there should be a clinical suspicion of onchocerciasis regarding immigrants from endemic areas having skin lesions compatible with the disease's profile or asymptomatic patients having eosinophilia or unexplained high IgE. Moreover, skin snips from the buttocks region were very fruitful and treatment with ivermectin was seen to be safe. This is the largest case series regarding imported onchocerciasis described up to the present time

INTRODUCCIÓN: La oncocercosis está causada por Onchocerca volvulus que produce fundamentalmente trastornos cutáneos, prurito y alteraciones visuales. Diecisiete millones de personas están infectadas en 38 países; 31 de ellos en África subsahariana, 6 en América Latina y uno en la península arábiga. Más del 99% de los casos se producen en el África subsahariana, donde 120 millones de personas están en riesgo de infección. Mientras los trastornos oculares han sido bien documentados, los trastornos cutáneos no se han descrito con precisión. El objetivo de nuestro estudio es describir la epidemiología, las principales manifestaciones cutáneas y el tratamiento de la oncocercosis importada. MATERIAL Y MÉTODOS: Estudio retrospectivo de una cohorte de 400 pacientes atendidos en una unidad de referencia a lo largo de un período de 17 años con los principales datos demográficos, clínicos y de tratamiento. RESULTADOS: La mayoría de pacientes eran mujeres (55%) con una edad media de 37,5 ± 16,7 años. Todos los migrantes procedían de países subsaharianos. El síntoma dermatológico más frecuente fue el prurito. La ivermectina fue el fármaco de elección, describiéndose reacciones adversas en 11 pacientes (3,2%). CONCLUSIONES: Los resultados señalan de que se debe mantener una sospecha clínica de oncocercosis en inmigrantes procedentes de áreas endémicas y lesiones cutáneas sugerentes o en pacientes asintomáticos con eosinofilia o IgE inexplicada. Además, los pellizcos cutáneos de glúteos fueron altamente rentables. El tratamiento con ivermectina es seguro. Esta es la mayor serie de casos de oncocercosis importada descrita hasta la fecha

Dermatological manifestations in onchocerciasis: A retrospective study of 400 imported cases.

INTRODUCTION: Onchocerciasis is caused by Onchocerca volvulus and mainly leads to pruritus and skin and visual disorders, including blindness. Seventeen million people are infected in 38 countries; 31 of these are in sub-Saharan Africa, six in Latin America and one on the Arabian Peninsula. More than 99% of cases occur in sub-Saharan Africa where 120 million people are at risk of infection. Eye disorders have been well-documented; however, skin disorders have not been described accurately. The objective of our study was to describe the epidemiology, main skin manifestations and treatment of imported onchocerciasis. MATERIAL AND METHODS: A retrospective study was thus conducted by analysing the main demographic, clinical and treatment data regarding a cohort of 400 patients attending a reference clinical unit over a 17-year period. RESULTS: Most patients were female (55%) with mean age 37.5±16.7 years. All the migrants came from sub-Saharan countries. The most frequently occurring dermatological symptom was pruritus. Ivermectin had been used as first-line therapy and adverse reactions had been described in 11 patients (3.2%). CONCLUSIONS: The results indicate the fact that there should be a clinical suspicion of onchocerciasis regarding immigrants from endemic areas having skin lesions compatible with the disease's profile or asymptomatic patients having eosinophilia or unexplained high IgE. Moreover, skin snips from the buttocks region were very fruitful and treatment with ivermectin was seen to be safe. This is the largest case series regarding imported onchocerciasis described up to the present time.

Could polymerase chain reaction tests on conjunctival swabs be useful to diagnose herpetic keratitis?

INTRODUCTION: Diagnosis of HSV-1 keratitis (HK) is frequently based on clinical findings. Invasive specimens (corneal scrapings, biopsies) are required for microbiological diagnosis. Methods Corneal scrapings and conjunctival swabs were collected on patients with/without clinical suspicion of HK from 2007 to 2012.ResultsThe sensitivity, specificity, positive and negative predictive values for conjunctival swabs by PCR was 77.8, 92.1, 84.4 and 88.3, respectively. Discussion Conjunctival swabs by PCR may help in the diagnosis of HK, despite the limited sensitivity

INTRODUCCIÓN: El diagnóstico de queratitis herpética (QH) está basado normalmente en hallazgos clínicos. Para el diagnóstico microbiológico se requieren muestras invasivas (raspado corneal, biopsias).MÉTODOS: Raspados corneales y exudados conjuntivales fueron obtenidos de pacientes con/sin sospecha clínica de QH del ano˜ 2007 al 2012.RESULTADOS: La sensibilidad, la especificidad y los valores predictivos positivos y negativos para la PCR enexudados conjuntivales fueron 77,8, 92,1, 84,4 y 88,3, respectivamente. DISCUSIÓN: La PCR en exudados conjuntivales puede ayudar en el diagnóstico, a pesar de su limitada sensibilidad

Could polymerase chain reaction tests on conjunctival swabs be useful to diagnose herpetic keratitis?

INTRODUCTION: Diagnosis of HSV-1 keratitis (HK) is frequently based on clinical findings. Invasive specimens (corneal scrapings, biopsies) are required for microbiological diagnosis. METHODS: Corneal scrapings and conjunctival swabs were collected on patients with/without clinical suspicion of HK from 2007 to 2012. RESULTS: The sensitivity, specificity, positive and negative predictive values for conjunctival swabs by PCR was 77.8, 92.1, 84.4 and 88.3, respectively. DISCUSSION: Conjunctival swabs by PCR may help in the diagnosis of HK, despite the limited sensitivity.

[Ophthalmoscopic surveillance in treated patients with invasive Candida disease]. / Importancia de la vigilancia oftalmológica durante el tratamiento de la enfermedad invasora por Candida.

BACKGROUND: Invasive Candida disease (ICD) is the most common cause of endogenous endophthalmitis. There are two characteristic ocular signs: Candida chorioretinitis defined as retina and choroid lesions without vitreal involvement, and Candida endophthalmitis defined as chorioretinitis with extension into the vitreous with characteristic fluffy balls. The most common visual symptoms are blurred vision and floaters. AIMS: To define in which patients with ICD a surveillance ophthalmoscopic examination should be done. METHODS: We searched the PubMed/Medline data base Candida endophthalmitis in adult and paediatric patients with ICD. RESULTS AND CONCLUSIONS: The need of ophthalmoscopic examination in patients with ICD is controversial, partly due to the fact that early antifungal treatment leads to a significant decrease of endogenous Candida endophthalmitis. Routine ophthalmoscopic examination seems of little value in patients with positive blood culture, with early implementation of antifungal treatment, without symptoms of ocular infection and without impairment of the level of consciousness during the episode. However, ophthalmoscopic examination should be performed in children with candidemia and critically ill patients with documented ICD, in the second week of treatment, especially in echinocandin treatment.

Importancia de la vigilancia oftalmológica durante el tratamiento de la enfermedad invasora por Candida / Ophthalmoscopic surveillance in treated patients with invasive Candida disease

Antecedentes: La enfermedad invasora debida a Candida (EIC) es la causa más común de endoftalmitis endógena. Las 2 formas características de presentación son la coriorretinitis candidiásica, que afecta a coroides y retina sin afectar al vítreo, y la endoftalmitis candidiásica, con presencia de lesiones vítreas redondeadas. Los síntomas visuales más habituales son la visión borrosa y las miodesopsias. Objetivos: Valorar en qué paciente con EIC debe realizarse una exploración oftalmológica y el momento más apropiado. Métodos: Revisión bibliográfica en la base de datos PubMed/Medline sobre endoftalmitis asociadas a EIC en población pediátrica y adulta. Resultados y conclusiones: Hay controversia en cuanto a la necesidad de realizar una exploración de fondo de ojo a todos los pacientes con EIC, debido a que la generalización del tratamiento temprano en estos pacientes ha supuesto una disminución marcada del número de infecciones oculares y de su gravedad. En un paciente con EIC tratado de forma temprana, sin síntomas oftalmológicos y sin alteración del grado de con- ciencia que le impida referir síntomas visuales durante el seguimiento, es muy dudosa la utilidad del estudio oftalmológico sistemático. Sin embargo, en pacientes sin posibilidad de referir ninguna alteración visual en la fase inicial de la infección ocular, como son los pacientes pediátricos con candidemia o los pacientes críticos con EIC, la exploración oftalmológica es obligada entre la primera y la segunda semanas de tratamiento, especialmente en los tratados con equinocandinas, por su baja penetración ocular (AU)

Background: Invasive Candida disease (ICD) is the most common cause of endogenous endophthalmitis. There are two characteristic ocular signs: Candida chorioretinitis defined as retina and choroid lesions without vitreal involvement, and Candida endophthalmitis defined as chorioretinitis with extension into the vitreous with characteristic fluffy balls. The most common visual symptoms are blurred vision and floaters. Aims: To define in which patients with ICD a surveillance ophthalmoscopic examination should be done. Methods: We searched the PubMed/Medline data base Candida endophthalmitis in adult and paediatric patients with ICD. Results and conclusions: The need of ophthalmoscopic examination in patients with ICD is controversial, partly due to the fact that early antifungal treatment leads to a significant decrease of endogenous Candida endophthalmitis. Routine ophthalmoscopic examination seems of little value in patients with positive blood culture, with early implementation of antifungal treatment, without symptoms of ocular infection and without impairment of the level of consciousness during the episode. However, ophthalmoscopic examination should be performed in children with candidemia and critically ill patients with documented ICD, in the second week of treatment, especially in echinocandin treatment (AU)

[Ophtalmoscopic examination in critically ill non-neutropenic patients: Candida endophtalmitis]. / Fondo de ojo en el paciente crítico no neutropénico: endoftalmitis candidiásica.

Invasive Candida (IC) infection is the most common cause of endogenous endophthalmitis. Ocular candidiasis develops within three days and at least two weeks of fungemia. There are two characteristic ocular signs: Candida chorioretinitis defined as retina and choroid lesions without vitreal involvement, and Candida endophthalmitis defined as chorioretinitis with extension into the vitreous with characteristic fluffy balls. The most common initial visual symptoms are blurred vision and floaters. Amphotericin B, fluconazole and voriconazole are effective in the treatment of chorioretinitis; however, when vitreous is involved vitrectomy seems necessary. Early antifungal systemic treatment at first evidence of infection in patients at risk of IC, appears to decrease dramatically the incidence of endogenous fungal endophthalmitis, probably healing minimal chorioretinal infections. Routine ophthalmoscopic examination seems of little value in patients with positive blood culture, with early implementation of antifungal treatment, without symptoms of ocular infection and without impairment of the level of consciousness during the episode. However, periodic ophthalmoscopic examination should be performed in children with candidemia and critically ill patients with documented deep Candida infection.

Fondo de ojo en el paciente crítico no neutropénico: endoftalmitis candidiásica / Ophthalmoscopic examination in critically ill nonneutropenic patients: Candida endophthalmitis

La candidiasis invasora (CI) es la causa más común de endoftalmitis endógena.La afectación ocular se produce entre los tres y los 15 días siguientes a la fungemia.Las dos formas características de presentación son la coriorretinitis candidiásica,que afecta a coroides y retina sin afectar claramente al vítreo, y laendoftalmitis candidiásica, con presencia de lesiones vítreas redondeadas, deaspecto algodonoso (“perlas vítreas”), características de esta infección. Los síntomasvisuales precoces más habituales son la visión borrosa y las miodesopsias.Clásicamente la anfotericina B, posteriormente el fluconazol y,actualmente, el voriconazol, han demostrado su utilidad en el tratamiento de lacoriorretinitis, pero la efectividad disminuye en los casos de afectación vítrea sino se asocian a vitrectomía. La utilización temprana de antifúngicos a la primeraevidencia de infección en pacientes con riesgo de CI ha reducido de forma muyimportante la incidencia de endoftalmitis fúngica, probablemente abortandolesiones coriorretinianas incipientes. No parece indicado el examen rutinario defondo de ojo a pacientes sin hemocultivo positivo por Candida, aunque tenganfactores de riesgo. En pacientes con cultivo positivo, si han sido tratados conantifúngicos de forma precoz, no presentan clínica que sugieran afectación oculary no han sufrido alteración del nivel de conciencia durante el periodo deseguimiento, es muy dudosa la utilidad del estudio oftalmoscópico sistemático.Sin embargo, en los pacientes pediátricos con candidemia y enfermos críticoscon candidiasis invasora debe realizarse fondo de ojo de forma rutinaria

Invasive Candida (IC) infection is the most common cause of endogenousendophthalmitis. Ocular candidiasis develops within three days and at least twoweeks of fungemia. There are two characteristic ocular signs: Candida chorioretinitisdefined as retina and choroid lesions without vitreal involvement, andCandida endophthalmitis defined as chorioretinitis with extension into the vitreouswith characteristic fluffy balls. The most common initial visual symptoms areblurred vision and floaters. Amphotericin B, fluconazole and voriconazole areeffective in the treatment of chorioretinitis; however, when vitreous is involvedvitrectomy seems necessary. Early antifungal systemic treatment at first evidenceof infection in patients at risk of IC, appears to decrease dramatically the incidenceof endogenous fungal endophthalmitis, probably healing minimalchorioretinal infections. Routine ophthalmoscopic examination seems of littlevalue in patients with positive blood culture, with early implementation of antifungaltreatment, without symptoms of ocular infection and without impairment ofthe level of consciousness during the episode. However, periodic ophthalmoscopicexamination should be performed in children with candidemia and critically illpatients with documented deep Candida infection

Eyelid molluscum contagiosum in patients with human immunodeficiency virus infection.

PURPOSE. Molluscum contagiosum (MC) is a common viral infection in patients with human immunodeficiency virus (HIV) infection. This study aimed to describe the relationship between the presentation of MC and the stage of HIV infection as measured by T-cell subsets. METHODS. A retrospective study is presented of 11 patients with MC of the eyelids and HIV infection in whom their CD4+ T lymphocytes were determined. RESULTS. Ten patients were in stage C3. The overall mean CD4+ count, CD4+ percentage and CD4+/CD8+ ratio were 71.63, 4.37%, and 0.085, respectively. Seven patients have died of AIDS-related conditions; the mean survival time was 12 months and the median 9 months from the diagnosis of MC. CONCLUSIONS. MC of the eyelids appears in advanced HIV infection when the CD4+ counts are less than 80 cells/&mgr;l.