54-year-old immunocompetent Caucasian male presented with bilateral anterior uveitis with initial partial response to topical steroids.
Few months later, this progressed to panuveitis with fundus obscuring cataract, total posterior synechia, seclusion pupillae (Figure 1), and poor response to treatment. His visual acuity quickly deteriorated to PL in both eyes.
A detailed workup was done to rule out infectious etiology including TB, Syphilis, toxoplasma, and Herpes. All investigations came back negative.
Further systemic workup was done to exclude autoimmune aetiology. All autoimmune screens (ANA, ANCA, and rheumatoid factor) came back negative.
B scan showed diffuse choroidal thickening with mild exudative detachment and a diagnosis of lymphoma was considered (Figures 2(a) and 2(b), right eye and left eye, resp.).
Phacovitrectomy and vitreous biopsy from one eye (Figure 3) were inconclusive as they showed atypical lymphocytes with no microbiology growth.
Phacovitrectomy (Figures 4(a) and 4(b)), vitreous biopsy, and subretinal biopsy (Figure 5) were done for the second eye. The sample was sent in CytoLyt medium for cytology, which excluded lymphoma and pointed to numerous cocci-like organisms.
Culture of another subretinal sample yielded Aspergillus niger finally (Figure 6). The patient was treated with intravitreal amphotericin B (dose: 5 micrograms/0.1 ml). Uveitis bilaterally improved with vision improvement from PL to CF.
The patient was immunocompetent and investigations for HIV were negative; however, he admitted IV drug abuse, which could be the only risk factor found. Pulmonary aspergillosis was excluded by the chest physicians. Also, systemic workup by the medical team did not reveal any other systemic fungal infection.
Subsequent follow-up showed improvement of vision to 2/60 with subretinal scarring. The site of subretinal retinal biopsy healed with a chorioretinal scar. Retina remained attached with no subsequent procedures performed.