A UNIQUE CASE OF CANDIDA RETINITIS IN THE COVID-19 ERA

ABSTRACT

CASE A 56-year-old male with a history of asthma was admitted to the intensive care unit (ICU) for acute hypoxic respiratory failure. He was found to have sepsis secondary to pneumococcal pneumonia superinfected by COVID19. Labs showed elevated inflammatory markers. Chest x-ray initially demonstrated left lower lobe pneumonia but throughout the COVID-19 course, worsened to persistent multifocal pneumonia. The patient was intubated and treated with enoxaparin and a ten-day course of dexamethasone as well as antibiotics due to worsening clinical status. After the COVID-19 course resolved and the patient was extubated, he developed sepsis again - this time secondary to Candidemia. Treatment with intravenous micafungin was initiated and HIV antibodies screening returned negative. The patient began to report subacute visual changes including floating spots and blurry vision in the right eye without any other acute ocular symptoms. Upon ophthalmological exam, there were multiple white retinal lesions without vitreous involvement bilaterally on the macula indicating candida retinitis. Antifungal treatment with micafungin was changed to intravenous voriconazole for greater intraocular penetration. After seven days of intravenous voriconazole, two blood cultures came back negative for Candida. At this point, the patient was medically stable and was discharged on a six- week course of oral voriconazole. IMPACT/DISCUSSION: The COVID-19 pandemic changed the landscape of medicine. Not only have healthcare systems worked hard to treat the COVID-19 infections themselves but also the long-term effects that result from an infection. As treatment guidelines have been developed and honed, steroids appear at the forefront of therapy. However, this does not come without consequences as prolonged use of corticosteroids can dampen the body's immune system. This compounds the ability of COVID-19 pneumonia to result in a severely immunocompromised state that can subsequently expose the body to opportunistic infections. Candida albicans is an organism that exists in all humans in the gastrointestinal and genitourinary systems typically without impact. In severely immunocompromised individuals such as the patient in the case, hospital courses involving ICU care can lead to hematogenous spread of Candida. The candidemia leads to sepsis and may also present with rare clinical pictures such as Candida retinitis. For this reason, candidemia should prompt thorough evaluation of patients with an echocardiogram, abdominal computer tomography, and ophthalmologic exam. CONCLUSION: This case displays the ability of COVID-19 infections to provide an opportunity for rare infectious manifestations such as Candida retinitis. As the pandemic prolongs, proper treatment regimens must be reassessed for future use as these presentations may become more common.