Answer to the last #DiagnosticDilemma
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The answer to the last Diagnostic Dilemma (A 34-year-old man with a history of intravenous drug use and hepatitis C infection presented to the ophthalmology clinic with a 1-week history of pain and decreased vision in his right eye. The visual acuity was 20/400 in the right eye and 20/20 in the left eye. The slit-lamp examination of the right eye showed conjunctival injection and inflammation in the anterior chamber. Indirect ophthalmoscopy showed vitreous haze with yellow-white lesions on the retina and optic nerve. Following workup, surgery was performed and a white mass measuring 4 mm by 3 mm by 1 mm was seen adherent to the optic nerve.) is Fungal endophthalmitis

The examination of the left eye was normal. Blood cultures were negative, and transthoracic echocardiography showed no evidence of vegetations. Fungal endophthalmitis was suspected, and treatment with oral and intravitreal voriconazole was initiated. The vitreous lesions persisted despite antifungal therapy; therefore, the patient underwent a vitrectomy. During surgery, a white mass (measuring 4 mm by 3 mm by 1 mm) that was adherent to the optic nerve was identified and removed through an incision in the side of the cornea.

Pathological analysis of the mass revealed a necrotizing granuloma with fungal yeast forms on Gomori methenamine silver staining, a finding consistent with candida species. After surgery, the visual acuity in the patient’s right eye improved to 20/30, and he completed 6 weeks of oral voriconazole treatment. His vision was stable at the 6-month follow-up visit, and there was no evidence of recurrence.

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Source: NEJM
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