Opportunistic Quambalaria fungal endophthalmitis in fumarate-treated multiple sclerosis complicated by multifocal postinfectious cerebral vasculopathy

PURPOSE: To describe the clinical course, multimodal imaging, management, and outcome of a case of endogenous Quambalaria fungal endophthalmitis. METHODS: Single-patient case report. RESULTS: A 66-year-old man with newly diagnosed multiple sclerosis on fumarate therapy treated with oral corticosteroids for a presumed intermediate uveitis, developed progressive left intraocular inflammation. Referral to a quaternary centre and diagnostic vitreous sampling identified Quambalaria cyanescens. on culture and panfungal polymerase chain reaction . A route of infection could not be established with certainty: a preceding ocular injury with plant material and an earlier lower-limb cellulitis each offered a plausible mechanism Despite intravitreal anti-fungal therapy, two pars plana vitrectomies and systemic antifungals, inflammation persisted until a period of intensive, repeated intravitreal voriconazole injections administered during inpatient admission resulted in clinical regression. Multifocal cerebral vasculopathy occurred in the immune reconstitution phase following improvement of Quambalaria infection. CONCLUSION: Quambalaria is an exceptionally rare ocular pathogen that can cause aggressive endophthalmitis. . Vitrectomy and intensive intravitreal voriconazole arrested an infection that had progressed despite treatment; the globe was preserved, although final visual acuity was light perception.