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Aspergillus Endophthalmitis in Intravenous-Drug Users -- Kentucky

Since May 1989, three cases of Aspergillus endophthalmitis, a potential cause of irreversible vision loss, have been reported in Louisville, Kentucky. All three patients were intravenous-drug users (IVDUs).

The patients--ages 40, 32, and 24 years--had onsets of illness in May, August, and September, respectively. Two were male. Except for IV-drug use, no risk factors for this fungal endophthalmitis were identified. All three patients were seronegative for antibody to human immunodeficiency virus. Infection was unilateral in each patient and responded to treatment with amphotericin B and flucytosine following vitrectomy. All patients had some degree of permanent vision loss. In each case, diagnosis was made by culture of specimens obtained at vitrectomy; each culture grew Aspergillus flavus. None of the patients had systemic or other localized signs of infection.

Two of the patients lived in the same apartment complex. The third lived approximately 1 mile away. Each denied any contact with the others. Common IV-injection practices included diluting drugs with tap water and filtering this mix through cotton or cigarette filters. All patients injected cocaine and a combination of pentazocine and tripelennamine. Reported by: CC Barr, MD, A Walsh, Humana University Hospital, B Wainscott, MD, Jefferson County Health Dept, Louisville; R Finger, MD, Acting State Epidemiologist, Dept for Health Svcs, Kentucky Cabinet for Human Resources. Div of Field Svcs, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: Fungal endophthalmitis is a recognized complication of IV-drug use (1). Infection results from hematogenous spread after nonsterile injection (2). Fungal endophthalmitis can develop slowly over weeks and occurs more frequently with Candida than with Aspergillus (3). Other risk factors associated with Aspergillus endophthalmitis include the use of antibiotics, corticosteroids, and immunosuppressive therapy (3). Vision loss can be limited in some patients by aggressive antibiotic and surgical treatment (4).

Because Aspergillus species are ubiquitous molds and the patients reported here used common injection practices, the source of infection is difficult to determine. However, one possible explanation for the geographic and temporal clustering of these cases is a contaminated drug supply. Physicians should consider the diagnosis of fungal endophthalmitis in IVDUs with signs of intraocular infection.

References

  1. Elliott JH, O'Day DM, Gutow GS, Podgorski SF, Akrabawi P. Mycotic endophthalmitis in drug abusers. Am J Ophthalmol 1979;88:66-72.

  2. Sugar HS, Mandell GH, Shalev J. Metastatic endophthalmitis associated with injection of addictive drugs. Am J Ophthalmol 1971;71:1055-8.

  3. Hirst LW, Thomas JV, Green WR. Endophthalmitis. In: Mandell GL, Douglas RG Jr, Bennett JE, eds. Principles and practice of infectious diseases. 2nd ed. New York: Wiley, 1985:760-7.

  4. Roney P, Barr CC, Chun CH, Raff MJ. Endogenous Aspergillus endophthalmitis. Rev Infect Dis 1986;8:955-8.

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