An outbreak of endogenous fungal endophthalmitis among intravenous drug abusers in New England

Abstract

IMPORTANCE: Intravenous drug abuse (IVDA) is a known risk factor for endogenous fungal endophthalmitis (EFE), a severe intraocular infection caused by hematogenous seeding of mycotic organisms to the eye. Reporting significant increases in heroin-related deaths since 2014, the New England region is in the midst of an opioid crisis that has led to a substantial increase in patients at risk for this vision-threatening disease. OBJECTIVE: To present an update on characteristics, management, and visual outcomes in patients with EFE. DESIGN, SETTING, AND PARTICIPANTS: Medical records review was initiated on July 1, 2016, evaluating all patients with EFE referred to New England Eye Center at Tufts Medical Center, a tertiary care ophthalmology practice distributed throughout Massachusetts, from May 1, 2014, to May 1, 2016. Patients with a history of IVDA and culture-proven or clinical evidence of fungal endophthalmitis were included. EXPOSURES: Intravenous drug use. MAIN OUTCOMES AND MEASURES: Patient demographics, comorbidities, presenting symptoms and vision, vitreoretinal findings, treatment regimens, culture data, and final visual acuities. RESULTS: Ten patients (5 women) with IVDA-related EFE were identified between May 1, 2014, and May 1, 2016-an increase from 3 patients treated from May 2012 to April 2014. The mean (SD) patient age was 34 (11) years (range, 24-60 years). Presenting visual acuities ranged from 20/25 to hand motion. The most common presenting symptoms were floaters (n = 8), reduced vision (n = 6), and pain (n = 5). Initial treatment included systemic antifungals in all patients and intravitreal antifungals in 9 eyes. Five patients required pars plana vitrectomy for worsening vitritis. The most commonly isolated pathogen was Candida albicans in 20% of the patients. Final visual acuity ranged from 20/40 to 20/300. CONCLUSIONS AND RELEVANCE: The data provided in this report suggest that EFE represents severe end organ damage associated with IVDA and portends poor visual outcomes. Health care professionals must maintain a high suspicion for EFE, as patients are typically ambulatory on presentation without systemic signs of infection.