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Central Scotoma After Liver Transplant

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 54-year-old man with a medical history of poorly controlled diabetes and hepatitis C–associated liver failure presented with a new central scotoma of the right eye 3 days after orthotopic liver transplant. He denied eye pain, floaters, and photopsias.

The patient had his first liver transplant 12 years before presentation that failed despite immunosuppressive treatment with tacrolimus. He initiated mycophenolate mofetil treatment 2 months before his second transplant. In addition, the patient was positive for cytomegalovirus (CMV) IgG antibodies and had an undetectable CMV load 1 month before transplantation.

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Presumed Aspergillus choroiditis

B. Perform a vitreous tap and administer intravitreal injection of antifungal agents

In an immunosuppressed patient after organ transplant, the presence of a large, creamy macular lesion with hemorrhage is highly suggestive of an infectious cause, particularly a fungus. The differential diagnosis includes Aspergillus, Candida, or bacterial endophthalmitis, CMV retinitis, and Toxoplasma retinochoroiditis.1

Of the available management options, intravitreal injections of antifungal agents (choice B) are most likely to successfully treat the infection. Neuroimaging and lumbar puncture (choice A) may be useful to assess for central nervous system infection; however, this option does not address the patient’s acute eye disease. Although CMV infection should be considered in an immunosuppressed patient with chorioretinitis, the morphologic features of the lesion were not consistent with CMV infection; thus, intravenous ganciclovir treatment (choice C) would not be helpful. Systemic steroids would be an inappropriate choice for a patient with suspected infection (choice D).

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Article Information

Corresponding Author: Bryn M. Burkholder, MD, Wilmer Eye Institute, Johns Hopkins University, 600 N Wolfe St, Maumenee 119, Baltimore, MD 21287 (bburkho1@jhmi.edu).

Published Online: November 15, 2018. doi:10.1001/jamaophthalmol.2018.3564

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Weishaar  PD, Flynn  HW  Jr, Murray  TG,  et al.  Endogenous Aspergillus endophthalmitis: clinical features and treatment outcomes.  Ophthalmology. 1998;105(1):57-65. doi:10.1016/S0161-6420(98)71225-3PubMedGoogle ScholarCrossref
2.
Hunt  KE, Glasgow  BJ.  Aspergillus endophthalmitis: an unrecognized endemic disease in orthotopic liver transplantation.  Ophthalmology. 1996;103(5):757-767. doi:10.1016/S0161-6420(96)30619-2PubMedGoogle ScholarCrossref
3.
Rao  NA, Hidayat  AA.  Endogenous mycotic endophthalmitis: variations in clinical and histopathologic changes in candidiasis compared with aspergillosis.  Am J Ophthalmol. 2001;132(2):244-251. doi:10.1016/S0002-9394(01)00968-0PubMedGoogle ScholarCrossref
4.
Theel  ES, Doern  CD.  β-D-Glucan testing is important for diagnosis of invasive fungal infections.  J Clin Microbiol. 2013;51(11):3478-3483. doi:10.1128/JCM.01737-13PubMedGoogle ScholarCrossref
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