Acute endophthalmitis and hyphema mimicking pink hypopyon associated with ocular toxocariasis: A case report





Abstract


Purpose


To report a case of acute endophthalmitis and hyphema mimicking pink hypopyon associated with ocular toxocariasis.


Observations


An immunocompetent 56-year-old woman presented to our hospital with a sudden onset and a three-day history of decreased visual acuity in her left eye. There were no known inciting factors for her symptoms; however, she had a history of eating undercooked beef five days prior. On examination, the best-corrected visual acuity of her left eye was light perception and the intraocular pressure was 24 mmHg. Hyphema mimicking pink hypopyon and vitreous opacity suggestive of acute endophthalmitis were observed in her left eye. The patient underwent an emergency pars plana vitrectomy. The intraoperative findings included iridodialysis, severe vitritis, multiple whitish spots on the retina, white sheathed retinal vessels, and whitish peripheral granuloma. The aqueous humor tap and vitreous tap cultures were negative. Blood tests showed elevated eosinophil and total immunoglobulin (Ig) E levels. Enzyme-linked immunosorbent assay of her intraocular fluid showed positive anti-Toxocara canis IgG reactions; the patient was therefore diagnosed with ocular toxocariasis. Subsequent treatment with oral albendazole and prednisone resulted in significant improvement and recovery of visual acuity to 20/12.5.


Conclusions and Importance


Acute endophthalmitis with hyphema mimicking pink hypopyon is a rare clinical presentation of ocular toxocariasis. The findings from this case highlight the importance of suspecting ocular toxocariasis if a patient presents with acute endophthalmitis and hyphema accompanied with peripheral granuloma. Early vitrectomy and subsequent treatment with oral albendazole and prednisone can be effective in visual recovery.



Introduction


Toxocariasis is an infectious disease caused by Toxocara canis and Toxocara cati. , The larvae of the Toxocara canis and Toxocara cati migrate to various organs, including lungs, liver, heart, brain, kidney, skin, and eyes. Two main forms of human toxocariasis have been established based on the place of migration and the associated clinical manifestations, namely: visceral larva migrans (VLM) and ocular toxocariasis (OT). Human toxocariasis is further classified into four types: VLM, OT, covert toxocariasis, and neurotoxocariasis.


OT is an intraocular infection. , The typical presentation of OT includes posterior pole granuloma, , peripheral granuloma, and chronic endophthalmitis. , However, no case of acute endophthalmitis with hyphema associated with OT has been reported till date. In this report, we present the details of a rare case of acute endophthalmitis with hyphema mimicking pink hypopyon as the initial manifestations of ocular toxocariasis, which was successfully treated with early vitrectomy followed by oral administration of albendazole and prednisone.



Case report


A healthy, immunocompetent 56-year-old woman presented to our hospital with a sudden onset and a three-day history of decreased visual acuity, blepharoptosis, and eyelid swelling in her left eye (OS). There were no known inciting factors for her symptoms; however, the patient had a history of eating undercooked beef that she cooked herself five days prior. She had been using anti-glaucoma eyedrops including tafluprost, timolol, and brinzolamid for the treatment of primary open-angle glaucoma. Her best-corrected visual acuity (BCVA) during her regular follow-up for glaucoma prior to the onset of the decreased visual acuity was 20/12.5 OS. She had no other ocular or general medical history. Her body temperature was 37.0 °C at the time of examination. On examination, the BCVA for her OS was light perception and the intraocular pressure was 24 mmHg. Pink colored hyphema mimicking pink hypopyon and diffuse conjunctival injection were observed on anterior segment examination ( Fig. 1 A and B). A dense vitreous opacity suspected to be suggestive of acute endophthalmitis was observed on B-scan ultrasonography ( Fig. 1 C). The patient underwent an emergency 25-gauge pars plana vitrectomy (PPV) with phacoemulsification and aspiration. The intraoperative findings included hemorrhage in the anterior chamber and vitreous due to iridodialysis, a thick fibrin membrane anterior to the iris, severe vitritis, whitish peripheral granuloma protruding toward the vitreous cavity, multiple whitish spots on the entire retina, and non-perfused white sheathed retinal vessels mimicking septic emboli ( Fig. 2 ). The anterior chamber tap and vitreous tap cultures were negative. Histopathological examination revealed no malignant cells in the vitreous sample. Chest and abdominal computed tomography findings were normal. There were no signs suggestive of uveitis due to tuberculosis, syphilis, toxoplasma, fungus, or viral infection. Blood test results showed elevated levels of total immunoglobulin (Ig) E (2385.1 IU/mL). Enzyme-linked immunosorbent assay of intraocular fluid collected three days after the PPV showed positive anti-Toxocara canis IgG reactions, with an optical density (OD) value of 0.37 (positive control, 1.507; negative control, 0.062) ( Fig. 3 ). Therefore, the patient was diagnosed with OT. Western blotting for the detection of serum anti-Toxocara canis IgG returned negative results.




Fig. 1


Preoperative images of the left eye of a 56-year-old woman with ocular toxocariasis at initial presentation. (A) Slit-lamp photograph. (B) Magnified image of a slit-lamp photograph showing hyphema mimicking pink hypopyon. (C) B-scan ultrasonography image showing vitreous opacity indicative of endophthalmitis. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)



Fig. 2


Intraoperative images obtained during pars plana vitrectomy and phacoemulsification and aspiration. (A) Image of the anterior segment at the beginning of surgery. (B) Removal of the hemorrhage and the fibrin membrane anterior to the iris using capsule forceps. Iridodialysis (*) was identified during surgery. (C) Three port 25-gauge vitrectomy. Wide-viewing system shows hemorrhage originating from iridodialysis and severe vitritis. (D) Whitish peripheral granuloma (white arrowheads) protruding toward the vitreous cavity. (E) Whitish spots on the retina (black arrows) and non-perfused white sheathed retinal vessels mimicking septic emboli. (F) Whitish spots on the peripheral retina (black arrows). (G) Whitish peripheral granuloma under scleral depression (black arrow). (H) Image of the anterior segment at the end of surgery. Posterior capsulotomy was performed. The intraocular lens was not implanted.

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Jan 3, 2022 | Posted by in OPHTHALMOLOGY | Comments Off on Acute endophthalmitis and hyphema mimicking pink hypopyon associated with ocular toxocariasis: A case report
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