Todokoro Daisuke, Hoshino Junki, Yo Ayaka, Makimura Koichi, Hirato Junko, Akiyama Hideo
Department of Ophthalmology, Gunma University Graduate School of Medicine, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan.
Laboratory of Space and Environment Medicine, Graduate School of Medicine, Teikyo University, Tokyo, Japan.
BMC Ophthalmol. 2018 Feb 13;18(1):40. doi: 10.1186/s12886-018-0707-4.
Ubiquitous fungi of the Scedosporium apiospermum species complex (SASC) cause various opportunistic infections. Posterior subtenon triamcinolone acetonide (STTA) injection is a standard therapy for intraocular inflammation and macular edema. We report a case of Scedosporium apiospermum infectious scleritis after a posterior STTA injection.
A 75-year-old man received a posterior STTA injection to treat macular edema in his left eye. After 3 months, he complained of ocular pain and hyperemia in his left eye. Examination showed a subtenon abscess in the site corresponding with the STTA injection. After incising the abscess, the smear revealed numerous conidia-like structures. Although we suspected fungal infection and started topical voriconazole (VRCZ) and levofloxacin, the inflammation of the eye worsened. Fungal culture revealed filamentous fungus growth. Subsequently, we added systemic VRCZ and performed surgical debridement of the infected sclera and Tenon's capsule. Pathology of the sclera showed fungal hyphae. The antifungal susceptibility test revealed low minimum inhibitory concentrations for micafungin, VRCZ and miconazole (0.06, 0.25 and 0.5 μg/mL, respectively). After 2 months, the ciliary injection subsided and VRCZ therapy was stopped. However, subtenon abscess recurred 1 month after discontinuation of topical VRCZ. Surgical debridement and topical VRCZ were resumed, with the eye finally improving after 5 months of management. The fungal species was identified as Scedosporium apiospermum sensu stricto morphologically and by DNA sequencing.
This case was successfully treated by topical and systemic VRCZ and repeated surgical debridement. Infectious scleritis caused by SASC rarely develops after posterior STTA. SASC can produce conidia in the enclosed subtenon space. Late-onset infectious scleritis after a posterior STTA injection suggests the presence of a fungal infection, including SASC, thereby requiring extensive and prolonged medical and surgical treatment.
阿氏丝孢酵母复合种（SASC）中的常见真菌可引起各种机会性感染。后Tenon囊内注射曲安奈德（STTA）是治疗眼内炎症和黄斑水肿的标准疗法。我们报告1例后STTA注射后发生阿氏丝孢酵母感染性巩膜炎的病例。
一名75岁男性接受后STTA注射以治疗左眼黄斑水肿。3个月后，他主诉左眼疼痛和充血。检查发现与STTA注射部位相对应处有Tenon囊下脓肿。切开脓肿后，涂片显示大量分生孢子样结构。尽管我们怀疑是真菌感染并开始局部使用伏立康唑（VRCZ）和左氧氟沙星，但眼部炎症仍加重。真菌培养显示有丝状真菌生长。随后，我们加用全身VRCZ并对感染的巩膜和Tenon囊进行手术清创。巩膜病理显示有真菌菌丝。抗真菌药敏试验显示米卡芬净、VRCZ和咪康唑的最低抑菌浓度较低（分别为0.06、0.25和0.5μg/mL）。2个月后，睫状充血消退，停用VRCZ治疗。然而，停用局部VRCZ 1个月后Tenon囊下脓肿复发。再次进行手术清创并恢复局部使用VRCZ，经过5个月的治疗，眼部最终好转。通过形态学和DNA测序将真菌鉴定为狭义阿氏丝孢酵母。
该病例通过局部和全身使用VRCZ以及反复手术清创成功治愈。后STTA后很少发生SASC引起的感染性巩膜炎。SASC可在封闭的Tenon囊空间内产生分生孢子。后STTA注射后迟发性感染性巩膜炎提示存在真菌感染，包括SASC，因此需要广泛且长期的药物和手术治疗。
