A 63-year-old man with a history of locoregionally advanced squamous cell carcinoma of the oropharynx is admitted to the hospital for cancer-related pain of the mouth and throat. The pain has slowly increased over the last several days and has limited his ability to eat and drink. The patient has felt weak and believes he is dehydrated. He was diagnosed with cancer 4 months ago and has received several cycles of chemotherapy and radiation therapy, the last of which occurred a week ago. He has been told that his tumor is unresectable. On admission, temperature was 36.1 C (97 F) , blood pressure was 105/60 mm Hg, pulse was 108/min, and respirations were 12/min. BMI was 17 kg/m². Physical examination showed periorbital wasting, dry mucous membranes, and sloughing of the oral mucosa. Absolute neutrophil count was 350/mm³. The patient was admitted to a medical floor and given intravenous pain control; total parenteral nutrition was initiated via a central venous catheter for malnutrition. On day 4 of hospitalization, the patient has a temperature of 39.1 C (102.4 F) and has developed right eye pain and light sensitivity. Funduscopic examination reveals several large, glistening, off-white lesions with indistinct borders. The lesions are 3-dimensional and extend from the chorioretinal surface into the vitreous. A vitreous haze is present and visual acuity is decreased. Item 1 of 2
What is the most likely cause of this patient's ocular pain?

Question

Quizplus · Accepted Answer

Explanation: This patient with oropharyngeal cancer on chemotherapy has neutropenia, putting him at risk for a wide range of infections. After beginning total parenteral nutrition through a central venous catheter, he developed high fever, eye pain, and evidence of fungating retinal lesions with vitreous extension, suggesting Candida endophthalmitis. Candida species are part of the normal flora of the human gastrointestinal and genitourinary tracts. Superficial infections of the mucous membranes (eg, vulvovaginitis) may occur with disruptions to local microbial balance (eg, antibiotic use), but deeper infections typically require neutropenia or severe illness that necessitates the intensive care unit (eg, burns). Central venous catheters, especially when used for total parenteral nutrition, may allow Candida species on the skin to access the bloodstream and disseminate to organs. The eye is frequently affected, and patients often have fever, decreased visual acuity, and eye pain. Funduscopic examination typically reveals focal, glistening, white, mound-like lesions on the retina that may extend into the vitreous, with resultant vitreous haze. (Choice A) Invasive aspergillosis typically manifests in the lungs (fever, dyspnea, pleuritic pain, hemoptysis) or sinuses. Endophthalmitis may occur rarely, but lesions are typically hemorrhagic and necrotic, not white and mound-like. (Choice C) Cryptococcal infections typically cause meningoencephalitis (headache, memory loss, personality change) or, less commonly, pneumonia. Cryptococcal endophthalmitis is exceedingly rare and is almost always associated with concomitant meningoencephalitis; this patient with central venous access on total parental nutrition is far more likely to have candidiasis. (Choice D) Infective endocarditis may cause microthrombi in the retina with a resultant immune-mediated vasculitis. This manifests as Roth spots, which are exudative, edematous retinal hemorrhages with pale centers. (Choice E) Mycobacterium avium complex may cause pulmonary or disseminated disease with fever, night sweats, and weight loss. Ocular disease is uncommon. Educational objective: Patients with neutropenia or severe conditions requiring the intensive care unit are at risk for invasive Candida infections. Risk is greatest in those with central venous access, particularly if the patient is on total parenteral nutrition. Endophthalmitis is a common finding in disseminated disease, and manifestations include fever, eye pain, decreased visual acuity, and funduscopic evidence of focal, glistening, white, mound-like lesions that may extend into the vitreous and cause vitreous haze.

A 63-Year-Old Man with a History of Locoregionally Advanced Squamous