Medical Mycology Case Reports 1 (2012) 39–41

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Medical Mycology Case Reports

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Ocular aspergillosis: Obtaining a specimen is crucial for diagnosis.

A report of three cases
Arzu Taskiran Comez a,n, Baris Komur a, Alper Akcali b, Muserref Tatman Otkun b
a
Department of Ophthalmology, School of Medicine, Canakkale Onsekiz Mart University, Canakkale 17020, Turkey
b
Department of Microbiology, and Clinical Microbiology, School of Medicine, Canakkale Onsekiz Mart University, Canakkale 17020, Turkey

a r t i c l e i n f o abstract

Article history: Aspergillus species have been implicated in a wide variety of primary ocular conditions, characterized
Received 2 May 2012 by either slow and asymptomatic infection, or rapid, uncontrollable progression and sometimes death.
Received in revised form The study design is a case series including chronic asymptomatic dacryocystitis, dacryocystitis with
18 May 2012
dacryoliths and endogenous endophthalmitis.
Accepted 4 June 2012
Due to this variable clinical presentation of aspergillosis a high level of suspicion must be
maintained as fulminant aspergillosis may lead to a rapidly progressive infection which may result
Keywords: in death.
Ocular aspergillosis & 2012 International Society for Human and Animal Mycology. Published by Elsevier B.V. All rights
Endophthalmitis
reserved.
Dacryocystitis
Aspergillus

1. Introduction one month postoperative follow-up visit, the patient expressed

that she was content with her cataract surgery (day 0). However,
Aspergillus is a fungus, usually considered a harmless saprophyte, she stated she had been experiencing tearing and secretion in the
which is ubiquitous in the environment [1]. Aspergillus infections operated eye for several years; this information was not divulged
commonly present as a localized disease of the lungs or paranasal to the surgeon prior to the cataract surgery. The lacrimal sac area
sinuses and mainly affect immunocompromised individuals [2]. looked normal; there was no edema, tenderness or regurgitation
Aspergillus dacryocystitis is a rare condition which is mostly with pressure (day 0). Syringing was facilitated, and both the
due to infection of the paranasal sinuses. Dacryoliths are typically inferior and superior canaliculi syringing were negative. However,
found in the setting of chronic infections with superimposed it was observed that the lacrimal sac was full with no drainage.
fungal colonization. They are found in up to 30% of patients with The patient stated that swelling occurred once every 15-days and
chronic dacryocystitis [3]. she drained it into her eye by pressing it with her finger.
Endogenous Aspergillus endophthalmitis is most commonly Dacryocystography with lipiodol revealed an atonic sac with
reported in immunosuppressed patients with organ transplants obstruction below the sac. The patient underwent transcanalicu-
or after valve replacement and in individuals suffering from lar multidiode laser-assisted dacryocystorhinostomy (DCR) with
hematological malignancies [4–6]. It may also be the presenting silicone tube intubation (day 7). Conjunctival cultures were
feature of disseminated aspergillosis [6]. obtained preoperatively from the involved and normal sides of
We report here three patients infected with two Aspergillus the patient and specimens were obtained from the lacrimal sac
species with different clinical appearances. Species identification of perioperatively via the endonasal route after the first burn from
isolates was made by macroscopic and microscopic morphology. the laser was seen in the nasal mucosa. Microscopic examination
of the samples showed typical Aspergillus hyphae (Fig. 1a). The
cultures were positive for Aspergillus niger (Fig. 1b). Treatment
2. Case 1 with Amphotericin-B, -topically and locally by syringing the sac
after DCR, provided a cure supported by repeated cultures.
A 74-year old immunocompetent female with left eye blind-
ness due to glaucoma and bullous keratopathy, had phacoemul- 3. Case 2
sification in the right eye in our clinic one month prior to
admission with no signs of dacryocystitis (day-30). During the A 29-year old immunocompetent female with a fistulated
lacrimal sac phlegmone with multiple white dacryoliths appear-
n
Corresponding author. ing at the opening of the fistula is presented (day 0) (Fig. 2a). The
E-mail address: arzucomez@yahoo.com (A.T. Comez). stones occurred in multiple, and they were 2–3 mm in diameter,

2211-7539/$ - see front matter & 2012 International Society for Human and Animal Mycology. Published by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.mmcr.2012.06.002
40 A.T. Comez et al. / Medical Mycology Case Reports 1 (2012) 39–41

Fig. 2. The opening of the lacrimal fistula with multiple grayish white dacryoliths
Fig. 1. Patient 1: Gram stain of the lacrimal sac contents revealed septate hyphae (A). Aspergillus fumigatus colonies on Sabouraud dextrose agar plate (B).
(A). Patient 1: Lacrimal sac cultures were positive for Aspergillus niger (B).

soft, of a grayish-white color and were able to be mashed easily

between the fingers. Pus and mucus filled the remainder of the
enlarged sac.
Conjunctival samples were obtained preoperatively from the
involved and normal sides of the patient (day þ7). Dacryolith
removal as well as excision of the fistula opening was facilitated
besides transcanalicular multidiode-laser DCR and silicone tube
implantation (day þ7).
Specimens were obtained from the lacrimal sac via nasal
endoscope for microbiological examination at the time of DCR.
Cultures obtained from the lacrimal sac grew Aspergillus fumigatus
(Fig. 2b). Bacterial cultures were negative. Treatment with topical
application and local syringing of the sac with Amphotericin-B
after DCR, provided a cure as supported by repeated cultures.

4. Case 3

An 11-year old boy diagnosed with acute lymphocytic leukemia, Fig. 3. Enucleation is performed due to massive necrosis and perforation of
was consulted by the pediatrician with a severe eye infection along the globe.
with severe pneumonia of an unidentified etiology (day 0). The
ophthalmological examination revealed severe endophthalmitis in (Fig. 3). Microbiological examination revealed A. niger. Despite
the right eye with swelling of the eyelids and ocular adnexa, corneal systemic Amphotericin-B application, septicemia caused death.
perforation and scleral necrosis with black pigmentations. On
admission, the patient was afebrile and had no light perception
(day 0). Although macroscopically and clinically aspergillosis was 5. Discussion
suspected, due to the severity of the pain and lack of light
perception, scleral melting and due to the urgency to determine Aspergillus species are usually considered a harmless sapro-
lung disease, the patient’s right eye was enucleated (day þ2) phyte, which are very common in the environment. They rarely
 A.T. Comez et al. / Medical Mycology Case Reports 1 (2012) 39–41 41

cause invasive or noninvasive infection in immunocompetent infections to rapid, disseminated disease resulting with death.
hosts. Since the early diagnosis of aspergillosis depends on suspicion,
Acute dacryocystitis is characterized by sudden pain, edema, followed by fungal culture findings, we emphasize that obtaining
erythema, and epiphora, in the medial epicanthal area. Infection diagnostic material routinely from the appropriate tissues with
of the lacrimal sac mostly mimics normal conjunctival flora and in appropriate techniques for microbiological examination in all eye
only 1.2% of cases, a fungus is the causative organism [7]. infections is crucial. Hence, it can be easily facilitated even in
However, in chronic dacryocystitis, Aspergillus and Candida laser-assisted DCR patients.
species may cause a superinfection [8–10]. Dacryocystitis and
blepharitis due to A. niger, lacrimal sac plugging caused by A.
fumigatus and chronic dacryocystitis in a healthy 3 year-old boy Conflict of interest statement
caused by Aspergillus flavus have previously been reported [8–10].
It is a common consensus that dacryocystorhinostomy (DCR) There are none.
should be performed before cataract surgery in order to minimize
the possibility of postoperative endophthalmitis caused by the
organisms retained within the lacrimal system. In patients with Acknowledgments
epiphora, lacrimal sac mucocele and obstruction of the passage,
DCR surgery should be performed before cataract surgery. How-
There are no acknowledgments for this paper.
ever, Case 1 did not show any signs of epiphora or edema in the
lacrimal sac region at the time of cataract surgery due to the
regular drainage of the sac by digital pressure performed by the References
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