Immunosuppressants

Abstract

Histoplasma capsulatum infection: case report A 45-year-old man developed Histoplasma capsulatum infection during treatment with triamcinolone, prednisolone and prednisone for robust inflammation, and secukinumab for ankylosing spondylitis [not all routes and dosages stated; duration of treatments to reaction onset not stated]. The man had a history of HLA-B27 associated with ankylosing spondylitis and anterior uveitis, and had been on secukinumab, initially presented to the hospital with a chief complaint of progressively worsening vision in both eyes. Subsequently, he underwent sequential cataract surgery in both eyes one month apart. He received perioperative intravitreal triamcinolone, topical prednisolone and oral prednisone to control his robust inflammation. Post-operatively, his treatment was successfully tapered off and remained inactive on secukinumab. Six weeks after the second cataract surgery, he presented to the hospital with mild irritation in both the eyes. Ocular examination showed visual acuity of 20/30 and 20/50 in right and left eyes, respectively. Eye examinations demonstrated central whitening, sub-conjunctival purulence and scleral necrosis with diffuse temporal scleral injection, more severe in the left eye without evidence of intraocular inflammation. The left anterior vitreous showed residue of triamcinolone. Anterior segment optical coherence tomography of these lesions revealed hypoechoic cysts within the sclera with thickening of the temporal sclera. Later, the conjunctiva was punctured and the subconjunctival purulence from both eyes was cultured. Initially, he was started on moxifloxacin treatment. No growth of the cultures was noted for 3 days, and his exams remained unchanged. Additionally, he was started on oral prednisone 50mg. One week later, his left eye fungal culture stained with lactophenol cotton blue showed tuberculate macroconidium consistent with Histoplasma capsulatum, which was confirmed by DNA accuprobe. Therefore, the man was started on itraconazole and amphotericin-B with a rapid taper of prednisone treatment. Chest X-ray was negative for intra-pulmonary nodules, suggested active pulmonary histoplasmosis. Later, infectious disease specialist evaluation was not associated with disseminated systemic disease and bilateral infectious necrotizing scleritis secondary to Histoplasma capsulatum was confirmed. Three days later, his right eye grew Histoplasma capsulatum. Therefore, he was treated with amphotericin for the next 2 months until the resolution of sub-conjunctival purulence, and maintained on a 6 months course of itraconazole. Nine months after the initial presentation with sub-conjunctival purulence, his visual acuity was found to be 20/30 in the right eye and 20/80 in the left eye without evidence of active scleritis. It was reported that his left eye visual acuity was limited by cystoid macular oedema secondary to HLA-B27 iritis.