Endophthalmitis Or Vitreous Hemorrhage?

CASE REPORTS AND SMALL CASE SERIES

Meningococcemia With Vitreous Opacities: Endophthalmitis or Vitreous Hemorrhage?

Visual acuity after treatment with meningococcal endophthalmitis is vari- able.1,2 A child with meningococcemia and disseminated intravascular coagulation (DIC) developed vitre- Figure 1. Left, External view of right eye shows periocular and conjunctival ecchymoses and edema ous opacities. Anterior segment in- without hypopyon. Right, Postvitrectomy view of the right fundus periphery shows chorioretinal scarring. flammation was never observed. time, vitreous opacities were be- Report of a Case. A 26-month-old, lieved to be hemorrhagic, second- previously healthy girl became le- ary to DIC, because ocular inflam- thargic with a petechial rash that pro- mation was absent. A second gressed to purpura. Intravenous ce- ultrasound examination 11 days later fotaxime sodium was given for demonstrated bilateral vitreous presumed meningococcemia. Blood opacities and a possible traction reti- cultures yielded Neisseria meningiti- nal detachment in the left eye. dis. Periocular ecchymoses prompted A pars plana vitrectomy, mem- an ophthalmic consultation. brane peel, gas fluid exchange, en- The patient was nonrespon- dolaser, and scleral buckle proce- sive and was receiving mechanical dure were performed in the left eye. ventilatory support during the ex- Extramacular areas of traction reti- amination. No relative afferent pu- nal detachment and necrotic retina Figure 2. A vitrectomy tissue specimen from pillary defect was present. The eye- were observed. The macula showed the left eye shows gram-negative intracellular lids and conjunctiva were edematous no abnormalities. Vitrectomy speci- organisms (arrow) (Gram stain, original and ecchymotic (Figure 1, left). In- men cultures were negative but magnification ϫ250). traocular pressures and portable slit- Gram stains demonstrated gram- lamp examination showed no ab- negative intracellular organisms with normalities. An undilated fundus vitreous hemorrhage (Figure 2). to a posterior subcapsular cataract. examination (due to the patient’s un- Pockets of neutrophils were ob- Cataract extraction and intraocular stable neurologic status) of the op- served in association with macro- lens placement were performed. Post- tic discs and posterior poles of both phages. Penicillin sodium was given operatively, the patient would not fix eyes showed no abnormalities. intravitreally in the right eye and and follow in the left eye. Amblyopia Multiorgan system failure de- subconjunctivally in both eyes for wasdiagnosedandfull-timeocclusion veloped with respiratory distress possible subclinical endophthalmi- therapy was started. syndrome, thrombocytopenia, DIC, tis. Intravitreal antibiotics were not and acute tubular necrosis requir- administered in the left eye be- Comment. Pain, photophobia, red- ing hemodialysis. Her unstable neu- cause signs of active infection were ness, decreased vision, and vitreal in- rologic status and high-frequency absent and intraocular gas was flammation are usually present with ventilation requirements pre- present. Three weeks later, vitrec- endogenous endophthalmitis. An- vented reliable sequential posterior tomy and scleral buckle were per- terior chamber inflammation, con- segment evaluations. The eyelid formed in the right eye. Intraopera- sidered typical of this condition, was edema and ecchymoses resolved. tive findings were similar to those in never seen in our patient. Four weeks after the initial exami- the left eye. We describe the occurrence of nation, anterior segments were still Postoperative visual acuity with meningococcal intracellular organ- quiet and bilateral dense vitreous correction was 20/40 OD and 20/80 isms associated with vitreous hemor- opacities were seen on dilated fun- OS. Extensive chorioretinal scarring rhages in a patient with meningo- dus examination. Retinochoroidal was seen (Figure 1, right) in the mid coccemia and DIC. The most likely thickening and vitreous cell were peripheral fundus. Subsequently, vi- explanation for the patient’s ocular noted on ultrasonography. At the sualacuitydecreasedinthelefteyedue lesions is subclinical meningoccal en-

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 dophthalmitis. The intravenous anti- Report of a Case. A 72-year-old biotics the patient received may have Conjunctival Melanoma Japanese man had a large pig- renderedtheorganismsnonviable,and Associated With Extensive mented area around his right eye the ocular findings may have been re- Congenital Conjunctival since birth, including the eyelid and lated to partially treated or subclini- conjunctiva. The black tone be- Nevus and Split Nevus cal endophthalmitis; however, throm- came more intense in the patient’s botic events from DIC could cause a of Eyelid first decade of life and had not similarclinicalfinding.IfDICwerethe changed since then. He first visited explanation,theneutrophil-containing Primary acquired melanosis and our institute on March 15, 1991, organisms may have entered the vit- acquired conjunctival nevi are rec- with his right vision obstructed by reous cavity in association with the ognized to be precursors of con- a black-brown nodule in the infe- hemorrhage. Necrotic areas of retina junctival melanoma; however, it rior bulbar conjunctiva. were likely the result of septic emboli has not been known that congeni- The visual acuity and intra- or vascular occlusion from DIC. tal conjunctival nevi can be a pre- ocular pressure showed no abnor- To avoid amblyopia, bilateral vit- cursor of conjunctival melanoma. malities. The right eyelid, conjunc- rectomies were necessary to clear the We report a case of fatal conjunctiva, and caruncle were black, and visualaxes.Thiscaseillustratestheim- tival melanoma in a 72-year-old the inferior aspect of the bulbar portanceofconsideringintraocularin- Japanese man. He was born with a conjunctiva had a black elevated fection in the setting of meningococ- large congenital black mole nodule. Small cystic lesions were cemiaandpresentsalternativehypoth- involving the right upper and present in other areas of the bul- eses to explain the clinical events. lower eyelids and conjunctiva. He bar conjunctiva (Figure 1 and had a brown-black nodule in his Figure 2). The ocular media, fun- Kristie K. Shappell, DVM, MS, MD inferior bulbar conjunctiva and dus, and optic nerve head showed Karen M. Gehrs, MD the right parotid and submandibu- no abnormalities. The right aspect Ronald V. Keech, MD lar lymph nodes showed marked of the parotid and submandibular Thomas C. Cannon, MD swelling. Chemotherapy was per- lymph nodes showed marked Robert Folberg, MD formed to clinically diagnose swelling that was hard and did not Iowa City, Iowa metastatic conjunctival mela- reduce in size despite antibiotic noma, but he died 5 months later therapy. This study was supported in part by due to systemic metastasis. Au- Metastatic malignant mela- an unrestricted grant from Research topsy revealed conjunctival melanoma of the conjunctiva was clini- to Prevent Blindness Inc, New York, noma associated with extensive cally diagnosed. Several treatment NY (Dr Folberg). conjunctival nevi and split nevus options, including orbital exentera- Reprints: Karen Gehrs, MD, De- of the eyelid. tion, radiation therapy, and chemo- partment of Ophthalmology and Vi- Seventy-five percent of con- therapy, were offered to the patient sual Sciences, University of Iowa Hos- junctival melanomas arise in and the family. They desired che- pitals and Clinics, Iowa City, IA 52242 association with primary acquired motherapy only. The patient’s con- (e-mail: [email protected]). melanosis.1 Histologic evidence of dition deteriorated; he died 5 months

1. Hull SH, Patipa M, Cox F. Metastatic endoph- nevus or a history of a conjunc- later due to systemic metastasis of thalmitis: a complication of meningococcal men- tival lesion dating to childhood malignant melanoma. ingitis. Ann Ophthalmol. 1982;14:29-30. may be discovered in 20% to 30% Autopsy revealed a mass of 2. Brinser JH, Hess JB. Meningococcal endophthalmitis without meningitis. Can J Ophthalmol. 1981; of patients with conjunctival mel- conjunctival melanoma, composed 16:100-101. anoma.1 of large epithelioid cells, in the

Figure 1. A 72-year-old Japanese man with a brown-black nodule in the Figure 2. Small, cystic lesions were present in other areas of the bulbar inferior aspect of the bulbar conjunctiva in the right eye. The eyelids and conjunctiva. bulbar conjunctiva had wide areas of pigmentation.

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 Figure 3. A gross photographic view of the tumor located in the inferior Figure 4. The tumor nodule is located in the conjunctiva (hematoxylin-eosin, bulbar conjunctiva. original magnification ϫ100).

Figure 5. The tumor is composed of moderately pigmented, markedly Figure 6. The bulbar conjunctiva has extensive compound nevi with cysts pleomorphic, large epithelioid cells (hematoxylin-eosin, original (hematoxylin-eosin, original magnification ϫ100). magnification ϫ400).

Figure 7. The skin of the eyelid, with foci of intradermal nevus present in the Figure 8. The nevus is composed of moderately pigmented, small round dermis (hematoxylin-eosin, original magnification ϫ100). cells (hematoxylin-eosin, original magnification ϫ400).

bulbar conjunctiva inferior to the conjunctiva. The palpebral con- Comment. Large congenital cuta- limbus (Figure 3, Figure 4, and junctiva and the intraocular com- neous nevi are associated with a risk Figure 5). Adjacent to the nod- ponents showed no abnormalities. of developing melanoma since child- ule, a narrow zone of pigmented Extensive intradermal nevus com- hood.1 Marghoob et al2 prospec- cells, possibly melanophages, was posed of small round cells (Figure 7 tively followed up 92 patients present in the episclera (Figure 3, and Figure 8) were present on the (median age, 3 years) with large con- Figure 4, and Figure 6), that was skin of the eyelids. The nevus cells genital cutaneous nevi for an aver- extensively observed around the had features of congenital cutane- age of 5.4 years and found that the globe. Nests of cystic compound ous nevus, with deep penetration cumulative 5-year, life-table risk for nevus (Figure 6) were extensively in the skin and maturation at the the development of malignant mela- present in other areas of the bulbar base. noma was 4.5%. The calculated stan-

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 dardized morbidity ratio (adjusted Reprints: Yoshiaki Nawa, MD, De- (70%-90% of the cases) with a me- relative risk) was 239-fold.2 partment of Ophthalmology, Nara ningoencephalitis or a subacute men- It is known that congenital blue Medical University, Kashihara, Nara ingitis and, to a lesser extent, the skel- nevi of the eyelids and orbit can lead 634-0813, Japan. eton, eyes, and skin.2 We describe a to eyelid and orbital melanoma. Tel- 1. Folberg R. Melanotic lesions of the conjunc- man affected by acquired immuno- lado et al3 studied 21 orbital mela- tiva. In: Spencer TH, ed. Ophthalmic Pathology: deficiency syndrome in whom dis- nomas. They found that 90% of pa- An Atlas and Textbook. 4th ed. Philadelphia, Pa: seminated infection with C neofor- WB Saunders Co; 1996:125-155. tients had an associated blue nevus 2. Marghoob AA, Schoenbach SP, Kopf AW, Or- mans started with a nodule on the and 47.5% of patients had some form low SJ, Nossa R, Bart RS. Large congenital me- border of his right eye. lanocytic nevi and the risk for the development of congenital melanosis. of malignant melanoma: a prospective study. Acquired conjunctival nevi are Arch Dermatol. 1996;132:170-175. Report of a Case. A 37-year-old man recognized to be precursors of con- 3. Tellado M, Spacht CS, McLean IW, Grossniklaus with acquired immunodeficiency HE, Zimmerman LE. Primary orbital melamo- syndrome had a 3-week history of junctival melanoma, but the risk of mas. Ophthalmology. 1996;103:929-932. congenital conjunctival nevi for the 4. Gerner N, Norregaard JC, Jensen OA, Prause JU. a papular lesion on the border of the developmentofmelanomaisunclear.1 Conjunctival naevi in Denmark, 1960-1980: a right side of his upper eyelid 4 21-year follow-up study. Acta Ophthalmol Scand. Figure 1 Gerner et al analyzed 343 sur- 1996;74:334-337. ( ). The clinical suspicion gically removed conjunctival nevi. Six 5. Kaneko A. Incidence of malignant melanoma of was of either a molluscum conta- the eye in Japan, 1977-1979. Nippon Ganka Gak- giosum or a neoplasm derived from cases that recurred during observa- kai Zasshi. 1982;86:332-355. tion were originally classified as com- 6. Grob JJ, Gouvernet J, Aymar D, et al. Count of be- the meibomian glands. The lesion pound nevi. Among them, 1 re- nign melanocytic nevi as a major indicator of risk was surgically removed. The pa- for nonfamilial nodular and superficial spread- curred as malignant melanoma. They ing melanoma. Cancer. 1990;66:387-395. tient’s immunologic test results were mentioned that in stationary and in- as follows: total leukocyte count, dolent cases in adults, excision as a 5 ϫ109/L; CD4+ cells, 0.019 ϫ109/L; routine procedure was unnecessary, CD8+ cells, 0.039 ϫ109/L; and the since the risk of evolution of conjunc- Eyelid Nodule: A Sentinel CD4+/CD8+ ratio, 0.05 (normal ra- tival nevi into melanoma was very Lesion of Disseminated tio, 1-2). The patient was taking an- low. In Japan, malignant melanoma Cryptococcosis in a tiretroviral therapy with indinavir of the conjunctiva is rare, with an es- Patient With Acquired (800 mg, 3 times daily), stavudine 5 timated 6 to 7 cases per year. Immunodeficiency Syndrome (40 mg, 2 times daily), and lamivu- In our patient, the history indi- dine (150 mg, 2 times daily). cates that large nests of nevus cells in- Cutaneous cryptococcosis is a rare Histopathologic examination volving bulbar conjunctiva, caruncle, infection caused by Cryptococcus neo- showed numerous cryptococcal or- and eyelid skin had been present since formans an encapsulated sapro- ganisms with large polysaccharide birth. Generally speaking, large phytic yeast. It is 4 to 8 µm in diam- capsules, surrounded by a granulo- nevi are associated with a risk of eter and is surrounded by a matous inflammation inside the su- developing melanoma.6 The many polysaccharide capsule that lives es- perficial and mid dermis (Figure 2). nevus cells of this patient probably pecially well in dust and soil con- Cryptococcal antigen was detect- increased the risk of developing taminated by the excreta of pi- able in serum (titer 1:8192) and ce- melanoma, a condition that should geons.1 The initial site of infection is rebrospinal fluid (titer 1:512). A be rare in Japanese patients. usually the lung, where cryptococ- chest x-ray film showed interstitial cosis occurs without symptoms and thickening, but a bone scan, a com- Yoshiaki Nawa, MD persists in a latent stage for a long puted tomographic scan of the cra- Yoshiaki Hara, MD time.2 Hematogenous dissemina- nium, and an ophthalmoscopic Mototugu Saishin, MD tion of the yeast may involve any or- examination showed no abnormali- Nara, Japan gan of the body, principally the brain ties. Therapy with amphotericin B,

Figure 1. Small papular lesion on the border of the right eyelid. Figure 2. Numerous cryptococci organisms surrounded by gelatinous capsules (periodic acid–Schiff, original magnification ϫ1000).

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 1 mg/kg per day, and flucytosine, low-up, the patient is well. Occa- Report of a Case. A 68-year-old 150 mg/kg per day, was started but sional relapses of the opportunistic man with an 8-month history of after 15 days additional multiple infection have been controlled with acute lymphotogenous leukemia dome-shaped, flesh-colored, umbili- amphotericin B. was seen in consultation for the cated papules, and ulcerated nod- hematology service. He com- ules appeared on the face, arms, and Loriana Coccia, MD plained of a red, protruding left eye the dorsal aspect of the hands. The Donato Calista, MD and progressive diplopia over 3 complete clinical remission lasted 5 Antonio Boschini, MD days. He had been admitted to the weeks after therapy. Rimini, Italy hospital with neutropenic fevers 5 days earlier. Comment. Human cryptococcal dis- He had left periorbital edema ease is a potentially fatal infection Corresponding author: Donato Cal- and erythema (greatest inferomedi- that develops mainly in predis- ista, MD, San Patrignano Medical ally). Palpation of the affected area posed individuals with defective cell- revealed no crepitus or bony abnor- 1,3 Center, San Patrignano, 47037 Rimini, mediated immunity. Since the ad- Italy (e-mail: [email protected]). mality. Sensory divisions of the tri- vent of acquired immunodeficiency geminal nerve were intact. The left syndrome, cryptococcosis has be- 1. Murakawa GJ, Kershmann R, Berger T. Cutane- eye was displaced forward 2 mm and ous cryptococcus infection and AIDS: report of come more frequent, involving from 12 cases and review of the literature. Arch Der- laterally 2 mm. Best-corrected vi- 5% to 10% of patients during their matol. 1996;132:545-548. sual acuity was 20/20 OD and 20/25 life, 10% to 15% of whom had cu- 2. Wai FN, Ka TL. Cutaneous cryptococosis- OS. Pupillary responses were brisk 4 primary versus secondary disease: report of two taneous involvement. Most promi- cases and review of literature. Am J Dermatopa- with no relative afferent pupillary de- nent on the face and neck, less fre- thol. 1993;15:372-377. fect. Slitlamp examination showed quently located on the trunk and 3. Sarosi GA, Siberfarb PM, Tosh FE. Cutaneous no other abnormalities. Intraocular cryptococcosis: a sentinel of disseminated dis- extremities, the typical clinical cu- ease. Arch Dermatol. 1971;104:1-3. pressures were normal. Left eye ab- taneous manifestations are umbeli- 4. Calista D, Stagno A, Landi C. Cutaneous le- duction was notably diminished and sions of disseminated cryptococcosis as the ini- cated papules with a tiny, central tial presentation of advanced HIV infection. J Eur there was a large angle esotropia. hemorrhagic crust quite similar to Acad Dermatol. 1997;8:140-144. Retinal evaluation showed no ab- molluscum contagiosum.1 Less of- 5. Kestelyn P, Taelman H, Bogaerts J, et al. Oph- normalities. thalmic manifestations of infection with Cryp- ten, violaceous papules, vesicles in tococcus neoformans in patients with the ac- White blood cell count was 0.5 a varicelliform pattern, crusted quired immunodeficiency syndrome. Am J ϫ109/L, demonstrating profound plaques, subcutaneous nodules, or Ophthalmol. 1993;116:721-727. neutropenia. Computed tomo- 4 6. Muccioli C, Belfort Junior R, Neves R, Rao N. cellulitis have been reported. The Limbal and choroidal Cryptococcus infection in graphic scan (Figure 1) revealed a most frequent ophthalmic manifes- the acquired immunodeficiency syndrome. Am pansinusitis with a soft tissue den- J Ophthalmol. 1995;120:539-540. tations of infection with C neofor- 7. Charles NC, Boxrud CA, Small EA. Cryptococ- sity extending into the left infero- mans involve the posterior segment cosis of the anterior segment in acquired immu- medial aspect of the orbit. Needle of the eye with papilledema, optic nodeficiency syndrome. Ophthalmology. 1992; drainage of the left aspect of the max- nerve atrophy, endophthalmitis, 99:813-816. illary sinus produced 30 mL of thick, and choroiditis.5 One existing yellow fluid. Initial smears demon- report describes limbal and choroi- strated septated hyphae and were dal mass and another iris inflam- negative for bacteria. matory mass in patients with Scedosporium apiospermum Amphotericin B (1 mg/kg per acquired immunodeficiency syn- of the Orbit day) was immediately started and drome.6,7 itraconazole (400 mg/d) was added The prognosis depends on the Scedosporium apiospermum is an the next day. The fungus was iden- degree of the patient’s immunode- emerging fungal pathogen common- tified as S apiospermum (Figure 2) pression, the involvement of C neo- ly found in soil (even in hospital and the infectious disease consult- formans, and the prompt start of potted plants1) and polluted water. ant recommended aggressive treat- therapy.3,4 The patient we observed Ocular infection can occur includ- ment due to the relative in vitro in- is interesting because he showed a ing keratitis, conjunctival myce- sensitivity to antifungal therapy. single nondiagnostic lesion on the tome, endophthalmitis, and pan- Surgical debridement of the si- upper border of the eyelid as a sen- ophthalmitis. Reports of orbital nuses and orbit was recommended; tinel lesion that preceded the spread- involvement have been rare. We de- however, the patient declined this ing of the cryptococcal infection by scribe a 68-year-old man with leu- procedure. By day 2 of medical 5 weeks. A rapid diagnosis permit- kemia who developed an orbital sub- therapy, the patient’s fever cleared ted the prompt start of appropriate periosteal abcess from extension of and the edema and diplopia re- therapy. Notwithstanding this, our contiguous fungal pansinusitis. We solved. On the seventh day of medi- patient experienced an initial spread also review the role of pharmaco- cal treatment, there were no ocular of cryptococcal lesions on his skin therapeutics in the management of signs or symptoms. The patient was although then serum and the colony- this disease. Remarkably, this pa- discharged from the hospital on a stimulating factors titer of crypto- tient defervesced on antifungal regimen of identical doses of am- coccal antigens were decreasing therapy without aggressive surgi- photericin B and itraconazole. He slowly. Now, after a 22-month fol- cal debridement. had no orbital recurrences and died

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 Figure 1. Computed tomographic scan shows complete opacification of the maxillary sinuses bilaterally. Left, Periosteal thickening of the frontal and sphenoid sinuses and opacification of the left ethmoid sinus were also present (not shown). Right, A subperiosteal abscess was noted involving the left medial orbital wall.

bital extension of pansinusitis of S choice in this disease; however, an- apiospermum in a diabetic host. The tifungal therapy alone may be rea- patient had both liver and renal fail- sonable in patients unwilling or un- ure. He was treated with surgical able to undergo aggressive surgery. drainage and systemic amphoteri- Ideal dosage and duration of treat- cin B but died 3 months later from ment are unknown, although this unrelated complications. In 1984, patient’s clinical course may pro- Anderson et al5 described the suc- vide helpful information. cessful treatment of a 4-year-old boy who had suffered a penetrating or- Jason Jones, MD Figure 2. Scedosporium apiospermum, the bital injury with orbitocranial in- Steven E. Katz, MD asexual form of Pseudallescheria boydii, volvement of the infection. His Martin Lubow, MD consists of branched hyphae with ovoid conidia (lactophenyl-cotton blue, original magnification therapy included multiple surgical Columbus, Ohio ϫ240). interventions and intravenous amphotercin B and miconazole. In cases of localized disease, it 3 months later from complications seems as if local debridement of as Corresponding author: Steven E. Katz, of his leukemia. much of the fungus as possible, com- MD, William H. Havener Eye Cen- bined with systemic antifungal medi- ter, University Hospitals Clinic, Comment. Scedosporium apiosper- cation, provides the best chance of 5717 456 W 10th Ave, Columbus, OH mum is an opportunistic fungus cure.3,5 This organism is known to 43210. commonly found in soil and decay- have relative in vitro insensitivity to ing vegetation. In 1944, Emmons amphotercin B; however, recent re- 1. Summerbell RC, Krajden S, Kane J. Potted plants demonstrated that S apiospermum is ports have shown good clinical re- in hospitals as reservoirs of pathogenic fungi. My- the asexual form of Pseudallesch- sponses.3 Both itraconazole and mi- copathologia. 1989;106:13-22. 2. Bloom SM, Warner RRP, Weitzman I. Maxil- eria boydii. Prior to 1944, P boydii conazole (ie, imidazoles) have lary sinusitis: isolation of Scedosporium (mono- was known as Allescheria boydii.2 shown greater effectivity in vitro and sporium) apiospermum, anamorph of Petriel- may be used as monotherapy.3,6 lidium (allescheria) boydii. Mt Sinai J Med. 1982; This organism can, in cases of pen- 49:492-494. etrating injury, infect healthy indi- Combined treatment with ampho- 3. Cunningham R, Mitchell DC. Amphotericin B– viduals. Here, it produces an indu- tercin B and an imidazole seems responsive Scedosporium apiospermum infec- 3 tion in a patient with acute myeloid leukemia. rated lesion at the site of the injury. reasonable. J Clin Pathol. 1996;49:93-94. In immunocompromised patients, In our patient, needle drain- 4. Gluckman SJ, Ries K, Abrutyn E. Allescheria (pe- aggressive spread is common. Sys- age of the involved maxillary sinus triellidium) boydii sinusitis in a compromised host. J Clin Microbiol. 1977;5:481-484. temic sites of infectious mycoses in performed for diagnostic purposes 5. Anderson RL, Carroll TF, Harvey JT, Myers MG. the immunosuppressed include the also provided some therapeutic de- Petriellidium (allescheria) boydii orbital and brain abscesses treated with intravenous miconazole. lungs, joints, central nervous sys- compression. This, combined with Am J Ophthalmol. 1984;97:771-775. 2 tem, sinuses, and ears. amphotericin B and itraconazole, re- 6. Ksiazek SM, Morris DA, Mandelbaum S, Rosen- Orbital involvement of this or- solved the signs and symptoms of or- baum PS. Fungal panophthalmalmitis secondary to Scedosporium apiospermum (Pseudallesce- ganism has rarely been reported. In bital infection. Surgical debride- ria boydii) keratitis. Am J Ophthalmol. 1994;118: 1977, Gluckman et al4 reported or- ment may still be the treatment of 531-533.

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