A case report of ocular infection caused by Aspergillus fumigatus

Introduction

In recent years, with increases in organ transplants, cancer chemotherapy, and patients with acquired immunodeficiency, clinical cases of Aspergillus fumigatus (A. fumigatus) infections have significantly increased (1-3).

Endophthalmitis is a severe ocular infection usually caused by bacteria or fungi. The disease affects the inner layers of the eye, vitreous, and sclera, leading to inflammation of ocular tissues. Without timely diagnosis and treatment, vision loss can be permanent. Cases of fungal endophthalmitis are relatively rare.

Fungal endophthalmitis is an infectious eye disease caused by pathogenic fungi. This disease is classified into exogenous and endogenous infections based on the pathogen. Exogenous infections are primarily caused by Aspergillus and Fusarium: the former is more common in fungal endophthalmitis resulting from plant injuries or intraocular surgery, whereas infections from the latter often follow fungal corneal ulcers. Endogenous infections are caused mainly by Candida albicans, followed by Aspergillus (4).

Risk factors for endogenous endophthalmitis include diabetes, chronic immunosuppressive diseases, urinary tract infections, liver abscesses, a history of recent surgery, long-term central venous catheterization, hepatobiliary or gastrointestinal surgeries, and inappropriate intravenous drug use (5-7). Endogenous endophthalmitis is relatively rare, accounting for 7.7–13.2% of all endophthalmitis cases (8).

Fungal endophthalmitis typically has a slow onset, with patients experiencing mild symptoms, such as eye pain, vision loss, floaters, mild ciliary congestion, and small amounts of hypopyon, and is rare in clinical practice. Thus, early diagnosis is crucial for treatment and prognosis. Diagnosis includes clinical and laboratory methods, with a definitive diagnosis relying on laboratory identification of the pathogen. There is increasing evidence that rare and environmentally derived fungi are emerging as significant ocular pathogens. Notably, phytopathogenic fungi (9) have been recognized as emerging agents with ocular tropism, capable of causing endophthalmitis even in immunocompetent individuals. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0116/rc).

Case presentation

A 44-year-old male was admitted to Huashan Hospital affiliated with Fudan University with a 1.5-month history of bilateral scleral icterus accompanied by progressive visual deterioration. The patient was previously diagnosed with acute liver failure [hepatitis B e-antigen (HBeAg)-negative chronic hepatitis B] at another hospital. During hospitalization, his vision in the left eye decreased. Ophthalmology consultation slit-lamp examination shows: left eye vision only perceives light, sclera is yellowish, mild ciliary congestion, cornea is clear, posterior corneal wall has exudation, aqueous humor in the anterior chamber is turbid, a small amount of white pus at the bottom, lens slightly cloudy, vitreous is flocculent and cloudy, fundus is hazy with what seems like a raised temporal peripheral retina. Preliminary diagnosis: left eye endophthalmitis, possible retinal detachment, admitted to our hospital. Examinations at admission confirmed the presence of hepatitis B virus (HBV) DNA, acute liver failure (Child-Pugh Class C), moderate anemia (78 g/L hemoglobin), and left endogenous endophthalmitis. Markedly elevated inflammatory markers included interleukin (IL)-6 (39.71 pg/mL), IL-8 (2,990.6 pg/mL), IL-1β (508.8 pg/mL), and interferon-gamma (IFN-γ, 60.8 pg/mL). All these parameters were significantly reduced postoperatively.

After obtaining informed consent, emergency vitrectomy of the left eye was performed, retinal detachment repositioning and laser photocoagulation for retinal lesions, cryotherapy for retinal lesions, and vitreous silicone oil implantation in the left eye, and vitreous fluid was collected during the operation for examination: (I) next-generation metagenomic sequencing (mNGS) on the third day confirmed A. fumigatus infection; (II) the vitreous fluid culture in the blood culture bottle showed Aspergillus; and (III) cytological analysis on the sixth day showed a significant increase in the proportion of neutrophils accompanied by necrosis. Giemsa staining revealed numerous septal hyphae, and the morphology was consistent with that of Aspergillus.

On the first and second days after the operation, empirical broad-spectrum anti-infection and liver-protecting treatments were administered. On the third day, after being diagnosed with Aspergillus fumigatus infection, local natamycin eye drops were applied, intravitreal injections of voriconazole were given, and voriconazole was also administered intravenously systemically, then switched to oral treatment after a week. During the treatment period, liver function and drug concentrations were monitored. After 6 weeks of treatment, vision gradually recovered to 0.3, the retina was flat and calm, and the condition gradually stabilized. At the 1-year follow-up, the patient’s condition remained stable, with no signs of inflammation or infection recurrence. It is basically consistent with the situations in the previous studies (3,8,10). A timeline summarizing both the clinical progression and the microbiological workup is shown in Figure 1.

Figure 1 Timeline of clinical management and microbiological investigation of the patient. mNGS, next-generation metagenomic sequencing.

Postoperative vitreous fluid was inoculated into aerobic and anaerobic blood culture bottles. After the aerobic blood culture bottle turned positive and showed white flocculent material (Figure 2A), aliquots were inoculated onto blood, China blue, and chocolate agar plates. After 24 h, white fluffy colonies had grown on the Chinese blue agar plates (Figure 2B) and were stained with lactophenol cotton blue. Microscopy examination revealed Aspergillus hyphae (Figure 2C).

Figure 2 Morphology and lactophenol cotton blue of pure culture colonies of A. fumigatus. (A) Aerobic blood culture bottle situation; (B) Chinese blue agar plate pure division colony morphology; (C) the microscopic staining morphology of A. fumigatus.

Pure colonies from the China blue agar plate were individually picked with a bamboo stick. Each colony was evenly spread on a target plate, followed by the addition of 1 µL of 70% formic acid. After drying at room temperature, 1 µL of matrix solution was added. Once dried, the sample was analyzed using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry using an Autof ms1000 system (Antu, Zhengzhou, China). The organism was identified as A. fumigatus, supporting the cytological findings.

The vitreous fluid samples were analyzed using mNGS. Specific sequences of A. fumigatus were detected (Figure 3). Based on clinical symptoms and laboratory test results, the final diagnosis was an infection caused by A. fumigatus.

Figure 3 Sequencing results.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Because fungal endophthalmitis is relatively uncommon clinically, there are very few reports in the literature. However, if left undiagnosed and untreated, this disease can very likely lead to permanent vision loss. This is precisely the significance of this case report.

Conclusions

Microscopy examination of Gram-stained samples and microbial culture remain the gold standards for identifying fungal infections (11,12).

Prevention and treatment of infectious endophthalmitis remain significant challenges for ophthalmologists and infectious disease specialists (13). Because diagnosis primarily depends on laboratory identification of the pathogen, improving detection techniques is crucial. Only by identifying the correct pathogen can clinicians provide targeted and personalized treatments based on susceptibility results, thereby improving treatment outcomes and patient prognosis (14,15).

In the absence of a confirmed identification of the responsible pathogen, physicians often start empirical antibiotic therapy at an early stage. While this strategy is necessary to keep the disease from progressing, it is not without limitations. Excessive use of broad-spectrum antibiotics driven by empirical treatment can ultimately lead to suboptimal microbial coverage (16). With the rapid development of technology, pathogen detection techniques are also constantly being innovated. Emerging methods such as mass spectrometry (for example, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry) and mNGS are increasingly demonstrating significant advantages. Especially, mNGS technology, with high sensitivity and efficiency, can achieve rapid and accurate etiological diagnosis in infections of unknown causes and pathogens under restricted culture conditions. In this case, the high accuracy and positivity rates observed with mNGS support its role as a beneficial auxiliary diagnostic approach. Using this method may help direct clinical management and enhance prognosis, since mNGS can detect pathogens regardless of whether they are already known or remain unidentified, including those that are difficult to cultivate using conventional culture methods. Additionally, it provides results within a shorter timeframe (48 h) (17,18). And mNGS also has some potential limitations, such as contamination, detection of non-viable organisms, or challenges in distinguishing colonization from infection. Some literature (19) has reported on the diagnostic methods and challenges of fungal keratitis, indicating that no single diagnostic method can independently achieve an accurate diagnosis. Accurate diagnosis relies on a combination of clinical evaluation, microbiological methods, and molecular techniques, each with its own inherent limitations. Although these studies mainly focus on keratitis, their findings are very relevant because they highlight the common diagnostic challenges in ocular fungal diseases, including endophthalmitis.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0116/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0116/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0116/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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