Eyelid Ulcer in an Immunocompromised Patient

Area of Science:

• Ophthalmology
• Infectious Diseases
• Rheumatology

Background:

• Immunosuppression, particularly from methotrexate (MTX) therapy, increases susceptibility to opportunistic infections.
• Eyelid ulceration can stem from various causes including malignancy, trauma, infection, and inflammation.
• Patients on MTX therapy are at elevated risk for infections like Purpureocillium lilacinum and Epstein-Barr virus (EBV)-associated mucocutaneous ulcers (EBVMCU).

Observation:

• An 82-year-old female with rheumatoid arthritis on chronic MTX therapy presented with a persistent left upper eyelid ulcer.
• Diagnostic cultures identified Purpureocillium lilacinum, while histopathology revealed EBV-positive atypical B cells.

Findings:

• The patient was diagnosed with concurrent EBVMCU and P. lilacinum infection of the eyelid.
• Discontinuation of MTX and treatment with oral voriconazole led to the resolution of the ulcer.

Implications:

• This case underscores the importance of considering concurrent fungal and viral infections in immunosuppressed patients presenting with unusual eyelid lesions.
• Prompt and accurate diagnosis, alongside appropriate antifungal and antiviral management, is crucial for successful treatment outcomes in such complex cases.
• Highlights the potential for rare opportunistic infections in patients undergoing immunosuppressive therapy.