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念珠菌性眼内炎和脉络膜视网膜炎的诊断与管理

Diagnosis and management of Candida endophthalmitis and chorioretinitis.

作者信息

Permpalung Nitipong, Sedik Sarah, Pappas Peter G, Hoenigl Martin, Ostrosky-Zeichner Luis

机构信息

Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Department of Internal Medicine, Medical University of Graz, European Confederation for Medical Mycology (ECMM) Excellence Center, Graz, Austria; Translational Mycology, Medical University of Graz, Graz, Austria.

出版信息

Clin Microbiol Infect. 2025 May 27. doi: 10.1016/j.cmi.2025.05.028.

Abstract

BACKGROUND

Candida endophthalmitis (CE) and chorioretinitis are uncommon but potentially devastating complications of candidemia, associated with significant risks of vision loss and long-term morbidity. Effective management relies on timely diagnosis and targeted antifungal therapy. However, diagnostic and therapeutic approaches are hindered by inconsistent guidelines, limited evidence, and variations in clinical practice.

OBJECTIVES

This review synthesizes current knowledge on CE and chorioretinitis to provide a comprehensive framework for clinicians. It addresses diagnostic challenges, including ophthalmoscopy, imaging, and microbiological diagnostics, and therapeutic strategies such as systemic and intravitreal antifungal therapies, surgical interventions, and serial ophthalmic evaluations.

SOURCES

An extensive literature search was conducted using PubMed, Embase, and Scopus, with a focus on epidemiology, pathogenesis, diagnostics, treatment, and outcomes. Guidelines from the Infectious Diseases Society of America, European Confederation for Medical Mycology, and American Academy of Ophthalmology were reviewed.

CONTENT

The prevalence of CE among patients with candidemia has increased from 1.8% in the pre-echinocandin era to 2.1% after the introduction of echinocandins. Diagnosis relies primarily on indirect ophthalmoscopy, the reference standard for retinal visualization. In selected cases, optical coherence tomography or fundus photography may support lesion assessment. Microbiological confirmation via vitreous sampling remains definitive but is often limited by low organism burden. Emerging diagnostics-such as clustered regularly interspaced short palindromic repeats-based fungal DNA assays-have shown promise. Although artificial intelligence-assisted imaging tools are established in other retinal diseases, they have not yet been validated for Candida ocular infections. Fluconazole and voriconazole remain first-line systemic therapies, with intravitreal injections and vitrectomy reserved for severe cases.

IMPLICATIONS

Improving outcomes in CE requires harmonized screening protocols, timely access to ophthalmologic care, and multidisciplinary collaboration. Future research should aim to refine diagnostic algorithms, define optimal treatment durations, clarify the role of emerging diagnostics, and leverage telemedicine and imaging technologies to improve early detection and longitudinal monitoring.

摘要

背景

念珠菌性眼内炎(CE)和脉络膜视网膜炎是念珠菌血症不常见但可能具有毁灭性的并发症,与视力丧失和长期发病的重大风险相关。有效的管理依赖于及时诊断和针对性的抗真菌治疗。然而,诊断和治疗方法受到指南不一致、证据有限以及临床实践差异的阻碍。

目的

本综述综合了关于CE和脉络膜视网膜炎的现有知识,为临床医生提供一个全面的框架。它探讨了诊断挑战,包括检眼镜检查、影像学检查和微生物学诊断,以及治疗策略,如全身和玻璃体内抗真菌治疗、手术干预和系列眼科评估。

资料来源

使用PubMed、Embase和Scopus进行了广泛的文献检索,重点关注流行病学、发病机制、诊断、治疗和结果。对美国传染病学会、欧洲医学真菌学联合会和美国眼科学会的指南进行了综述。

内容

念珠菌血症患者中CE的患病率已从棘白菌素时代前的1.8%增加到引入棘白菌素后的2.1%。诊断主要依赖间接检眼镜检查,这是视网膜可视化的参考标准。在特定情况下,光学相干断层扫描或眼底摄影可能有助于病变评估。通过玻璃体采样进行微生物学确认仍然是确诊依据,但通常受到低菌负荷的限制。新兴诊断方法,如基于成簇规律间隔短回文重复序列的真菌DNA检测,已显示出前景。虽然人工智能辅助成像工具在其他视网膜疾病中已确立,但尚未在念珠菌性眼部感染中得到验证。氟康唑和伏立康唑仍然是一线全身治疗药物,玻璃体内注射和玻璃体切除术用于严重病例。

启示

改善CE的治疗效果需要统一的筛查方案、及时获得眼科护理以及多学科协作。未来的研究应旨在完善诊断算法、确定最佳治疗持续时间、阐明新兴诊断方法的作用,并利用远程医疗和成像技术改善早期检测和纵向监测。

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