Diagnostic and therapeutic challenge of Aspergillus flavus scleritis

To discuss the diagnostic and therapeutic challenges involved in the management of Aspergillus flavus scleritis and present a review of related literature.

Case report and literature review.

A healthy 54-year-old woman presented with a 1-week history of severe pain and redness in her left eye. She was treated with prednisone for presumed idiopathic autoimmune scleritis after extensive evaluation revealed no apparent etiology. While on immunosuppressant therapy, the patient developed a scleral nodule that proved to be a scleral abscess with normal overlying scleral architecture. Culture of the abscess and extensive infectious disease evaluation did not offer an etiologic explanation. Biopsy of a subsequent scleral nodule revealed fungal hyphae on fixed tissue stains, and A. flavus was identified on fungal culture. The patient later acknowledged intravenous drug use in the 2 months preceding her presentation. Oral voriconazole and intravenous caspofungin along with repeated surgical drainage of emerging scleral abscesses eradicated the active disease after 3 months.

Despite its rare occurrence, Aspergillus sp. should be considered as a potential cause of an unusual progressive scleritis. Specific questioning regarding intravenous drug use may prove relevant. Scleral biopsy was instrumental in establishing the diagnosis. Aggressive multidrug medical therapy combined with repeated surgical debridement resulted in a positive clinical outcome.