final program.qxd - Parallels Plesk Panel

PP 6.24
Controversies in the antimycotic management of Candida albicans
panophthalmitis: an exemplary case report and discussion of guidelines of
antifungal chemotherapy
Roberto Manfredi, Sergio Sabbatani
Infectious Diseases, University of Bologna, Italy
Introduction
Candida endophthalmitis is a severe function-threatening infection, more frequent in
immunocompromised p, or among p with selected supporting conditions.
Case report
A 55-year-old man with an insulin-dependent diabetes was hospitalized due to a sudden
vision loss at right. After a diagnosis of C. albicans panuveitis, a treatment with i.v.
fluconazole (400 mg/day) was started. Since a worsening of ophthalmologicfluorangiographic
picture paralleled the appearance of amblyopia, 10 days later liposomal
amphotericin B (lAB) (at 3 mg/Kg/day) replaced fluconazole, and after 14 days a
remarkable reduction of exudates was achieved. After 17 days lAB was stopped due to
am overwhelming kidney function deterioration (serum creatinine 2.11 mg/dL, and
azotemia 1.32 g/dL, versus normal values upon admission), and i.v. caspofungin was
administered at standard dosage. After 48 days of caspofungin therapy (at 50 mg/day)
delivered on Day-Hospital basis, active foci were still present at fluorangiography, and
visual acuity recovered up to 2/10, while renal impairment spontaneously disappeared.
Finally, i.v. voriconazole (at 400 mg/day) was started and continued for 23 days. After this
last course, our p obtained a complete resolution of exudates at ophthalmoscopic-fluorangiographic
study, and visual acuity rose to 6/10. Oral voriconazole (400 mg/day) was
recommended upon discharge.
Discussion
The rationale of antifungal therapy of Candida endophthalmitis is limited by the
unfavorable kinetics of several compounds, and the absence of randomized controlled
trials in this setting, so that most informations come from small series and anecdotal
reports. While fluconazole may be limited by its reduced activity on some non-albicans
Candida, lAB is the standard of care (administered by intraocular and/or systemic route),
but isolated failures were reported. The endovitreal penetration of caspofungin is
discussed (although favorably treated p are described), while voriconazole (either as
systemic or local injection agent) led to preliminary, satisfactory results. Our p with a
severe Candida endophthalmitis received all the four available antimycotic agents
effective against C. albicans (i.e. fluconazole, liposomal amphotericin B, caspofungin, and
voriconazole), but experienced disease progression during fluconazole and probably
long-term caspofungin administration, while the initially favorable lAB response was
hampered by reversible kidney function anomalies, and voriconazole proved safe and
effective in leading to a complete cure and a favorable recovery of visual acuity.
Prospective, controlled studies are strongly needed, to trace some therapeutic guidelines
of Candida panophthalmitis.
POSTERS
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