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. Which of the following treatment options is likely to be of greatest benefit for this patient's condition?

Question

Quizplus · Accepted Answer

Explanation: Candida endophthalmitis is a vision-threatening infection and must be treated aggressively. Those who have endophthalmitis due to hematologic seeding (as in this case) typically develop chorioretinitis, which can then spread into the vitreous or aqueous. Patients with vitreous involvement usually require systemic antifungals such as amphotericin B, intravitreal antifungal injection, and vitrectomy (to reduce fungal microabscesses that may be recalcitrant to therapy). Treatment with systemic antifungals for 4-6 weeks is required. (Choice A) Clarithromycin and rifabutin are sometimes used in the treatment of disseminated Mycobacterium avium complex but are not effective antifungal medications. (Choice B) Vancomycin and gentamicin are sometimes used in combination in the empiric treatment of bacterial infections (eg, infective endocarditis). They do not have efficacy against fungal organisms such as Candida species. (Choice C) Systemic amphotericin B is an effective drug for Candida chorioretinitis; however, it does not reach adequate levels in the vitreous. Patients with vitreous involvement require intravitreal antifungal injections and, often, vitrectomy, in addition to systemic treatment. (Choice E) Although fluconazole and voriconazole may be used for treating Candida endophthalmitis, ketoconazole does not achieve high enough vitreous concentrations to be recommended. Educational objective: Candida endophthalmitis with vitreal involvement is typically treated with systemic antifungal medication (eg, amphotericin B), intravitreal antifungal injection, and vitrectomy.

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