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INTRODUCTION
A cardiac transplant patient presented to the Ochsner ophthalmology clinic with flashes of light in the left eye and a retinal lesion of unclear etiology.
CASE REPORT
A 59-year-old male presented to the Ochsner Medical Center Department of Ophthalmology retina service through a referral from an outside eye physician. The patient's chief complaint was flashes of light in the left eye starting 10 days prior.
The patient's medical history included a heart transplant 3 months prior. His postoperative course included a chest wound infected by Candida and treated with fluconazole, with negative blood cultures. The patient also recently had had a urinary tract infection that was culture positive for Pseudomonas aeruginosa and treated with levofloxacin. Blood cultures were again negative. The patient's medications included tacrolimus 3 mg every 12 hours, valganciclovir 450 mg daily, fluconazole 400 mg daily, and sulfamethoxazole/trimethoprim 800 mg/160 mg three times per week.
On examination, the patient's visual acuity was 20/50 in both eyes. The examination of the anterior chamber of his left eye revealed white blood cells distributed throughout the aqueous fluid, consistent with inflammation. On dilated fundus examination, the vitreous showed minimal signs of inflammation. However, a large hypopigmented lesion was discovered in the nasal retina of the left eye (Figure 1). The lesion was somewhat thickened with overlying hemorrhage and pigment. The blood vessels overlying the lesion appeared mildly attenuated but otherwise normal. No similar lesion was found in the right eye.
[image omitted: see PDF]
The differential diagnosis focused on possible opportunistic infection related to immunosuppression secondary to organ transplantation, including cytomegalovirus (CMV) retinitis, herpetic retinitis (progressive outer retinal necrosis vs acute retinal necrosis), Pseudomonas abscess, Candida chorioretinitis, toxoplasmic chorioretinitis, and infection by less common organisms such as Pneumocystis and Aspergillus. 1 Choroidal lymphoma was also considered.
The patient was admitted to the hospital under the transplant service, and the infectious disease service was consulted to aid in the patient's workup and management. Because of the possibility of Pseudomonas infection, intravenous piperacillin/tazobactam was initiated at a dose of 4.5 g every 6 hours....