What the Eyes Don't See, the Heart Does Grieve Over

A 71 year old Peruvian woman presented with blurry vision and bilateral eye pain and had evidence of bilateral endophthalmitis on eye examination. Her past medical history was notable for multiple abdominal surgeries within the preceding months, including an incarcerated inguinal hernia repair which required an ileostomy placement, and cholecystitis requiring cholecystostomy tube placement. Over her multiple long hospitalizations, she developed bacteremia and fungemia on several occasions, with organisms including Enterobacter cloacae, Klebsiella pneumoniae, Bacteroides fragilis, Pseudomonas aeruginosa, Enterococcus faecium, and Candida albicans. On exam, she was febrile and tachycardic. She had bilateral conjunctival injection, hypopyon, and severely decreased visual acuity. She also had a III/VI harsh holosystolic murmur at the apex. Her lungs were clear to auscultation. Transesophageal echocardiogram revealed severe mitral regurgitation and a 16 x 15 mm mitral valve vegetation and a perforated aneurysmal posterior mitral valve leaflet. The patient underwent bilateral vitrectomy and was treated with flucytosine and ambisome. Blood and vitreous humor cultures were obtained, but remained negative, likely due to being drawn after the patient had been empirically treated with antifungals and antibiotics. She continued to spike fevers and developed heart failure, but refused valve replacement surgery as she wished to return to her home country.

A systemic source of infection should be sought in the presence of bilateral endophthalmitis. In our case, we suspected seeding from endocarditis or an intra-abdominal infection, given the patient history of multiple complicated abdominal surgeries and recurrent bacteremia and candidemia. Based on the vegetation's large size and bilateral endophthalmitis, we believed Candida was the most likely culprit. Additionally, eye lesions observed during surgery appeared consistent with fungal endophthalmitis. Candida is a rare but very morbid cause of infective endocarditis. Arterial embolization and metastatic infections such as endophthalmitis are more frequent in candidal endocarditis, likely due to the generally larger vegetation size. Valve replacement should be strongly considered regardless of other factors, as some studies have shown a mortality benefit for antifungals and surgery compared to antifungals alone. In cases in which valve replacement is not feasible, the patient should be kept on lifelong suppressive antifungal therapy.