title: Chronic coccidioidomycosis endophthalmitis without concomitant systemic involvement: a clinicopathological case report.
abstract: OBJECTIVE
  To report the diagnostic, clinical, and histopathologic features of a patient with coccidioidomycosis endophthalmitis without concomitant systemic involvement diagnosed by vitreous biopsy.
  
  
  METHODS
  Interventional case report.
  
  
  METHODS
  One patient.
  
  
  METHODS
  Diagnostic pars plana vitrectomy, systemic and intravitreal antifungal treatment, and enucleation.
  
  
  METHODS
  Diagnostic, clinical, and histopathologic features of chronic coccidioidomycosis endophthalmitis.
  
  
  RESULTS
  A 64-year-old white man from Southern California presented with chronic intraocular inflammation in the right eye that had lasted 18 months. He had been unsuccessfully treated with topical and subtenon steroids. At presentation, best-corrected visual acuity was 20/400 in the right eye and 20/20 in the left eye. Ophthalmoscopy of the right eye revealed significant vitritis and multiple yellowish chorioretinal lesions. Evaluation by an internist showed no underlying inflammatory, infectious, or neoplastic systemic illnesses. A vitreous biopsy followed by histopathologic examination showed the presence of multiple Coccidioides sp. microorganisms. The patient was then treated with intravitreal amphotericin B and oral fluconazole. Best-corrected visual acuity initially improved to 20/80, but inflammation progressed and did not respond to 2 subsequent injections of antifungals, 2 additional pars plana vitrectomies, and oral fluconazole. The eye eventually became blind and painful and was enucleated. Histopathologic examination disclosed intraocular granulomas displaying multiple Coccidioides sp. microorganisms.
  
  
  CONCLUSIONS
  Coccidioides sp. endophthalmitis may present with no concomitant systemic involvement. Histopathologic examination of the vitreous is helpful in the diagnosis. A high index of suspicion is important, especially in areas where the incidence of coccidioidomycosis is rising.
authors.affiliation: Doheny Eye Institute and Department of Ophthalmology, Keck School of Medicine of University of Southern California, Los Angeles, California, USA.
authors.forename: Daniel V
authors.initials: DV
authors.lastname: Vasconcelos-Santos
authors.forename: Jennifer I
authors.initials: JI
authors.lastname: Lim
authors.forename: Narsing A
authors.initials: NA
authors.lastname: Rao
mesh_terms: D000935:Antifungal Agents / Q000627:therapeutic use; D001706:Biopsy; D002908:Chronic Disease; D003045:Coccidioides / Q000302:isolation & purification; D003047:Coccidioidomycosis / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D009877:Endophthalmitis / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D015353:Eye Enucleation; D015821:Eye Infections, Fungal / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D016469:Fungemia / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D014792:Visual Acuity; D014821:Vitrectomy; D014822:Vitreous Body / Q000382:microbiology
chemical_list: D000935:Antifungal Agents
references.citation: Curr Opin Infect Dis. 2008 Aug;21(4):415-20
references.pmid: 18594295
references.citation: Ophthalmology. 1980 Oct;87(10):974-84
references.pmid: 6972501
references.citation: Clin Chest Med. 2009 Jun;30(2):241-51, v
references.pmid: 19375631
references.citation: Ophthalmology. 1994 Dec;101(12):1923-8
references.pmid: 7997329
references.citation: Arch Ophthalmol. 1998 May;116(5):674-7
references.pmid: 9596507
references.citation: MMWR Morb Mortal Wkly Rep. 2009 Feb 13;58(5):105-9
references.pmid: 19214158
references.citation: Infect Dis Clin North Am. 2003 Mar;17(1):41-57, viii
references.pmid: 12751260
references.citation: Ann N Y Acad Sci. 2007 Sep;1111:301-14
references.pmid: 17363434
references.citation: Br J Ophthalmol. 2007 Jun;91(6):837-8
references.pmid: 17510480
references.citation: Surv Ophthalmol. 1980 Mar-Apr;24(5):263-90
references.pmid: 6988997
references.citation: Clin Infect Dis. 2005 Nov 1;41(9):1217-23
references.pmid: 16206093