S5072 A Fungal Phenomenon: Sudden Vision Loss in a Patient With Acute-on-Chronic Liver Failure

Introduction: Fungal endophthalmitis is one of the leading causes of vision loss worldwide. Risk factors include post-transplantation, IVDU, drug use, and immunocompromised individuals including HIV, malignancy, DM, lung disease, renal insufficiency, and chronic liver disease. Aspergillosis is the second most common cause of fungal endophthalmitis after Candidiasis. Most case reports involving patients with liver disease are post-transplantation, and only a few cases of fungal endophthalmitis have been reported in cirrhotic patients. We present a case of Aspergillus endophthalmitis in the setting of acute decompensated cirrhosis. Case Description/Methods: A 58-year-old man with medical history significant for metabolic and alcohol-related decompensated cirrhosis with jaundice and ascites and Type II DM presented for liver transplant evaluation. He initially presented for generalized weakness and found to be in septic shock secondary to Influenza A. He was admitted to the ICU where a femoral central line was placed for access and administered systemic steroids, oseltamivir, antibiotics, and vasopressors. He then suddenly developed blurry vision and pain in both eyes and was diagnosed with bilateral endophthalmitis. He underwent a vitreous tap which grew Aspergillus flavus. He empirically received intra-vitreous injections of antibiotics before continuing with voriconazole as well as intravenous voriconazole. ECHO was negative for any vegetation. MRI was negative for intracranial infection, and lumbar puncture was also negative. He underwent a pars plana vitrectomy for irreparable fundal retinal detachment and choroidal drainage of the right eye and retinal abscess of the left eye. He had no prior history of fungal or opportunistic infections. Over several months, his vision improved after extended voriconazole therapy. Discussion: Aspergillus endophthalmitis can rapidly lead to blindness and should be included in the differential, not only in post liver transplant patients, but also in cirrhotic patients. Symptoms include decreased vision, eye pain, and erythema. Common risk factors include central lines, TPN, broad-spectrum antibiotics, glucocorticoid therapy, intravenous drug use, abdominal surgery, and neutropenia. In this case, the patient had a recent central line with broad spectrum antibiotics and glucocorticoid therapy. Aspergillus endophthalmitis can be safely treated with intravenous voriconazole with intravitreal voriconazole or amphotericin B. Early testing and treatment can potentially be vision saving.