Abstract
RATIONALE: Endogenous fungal endophthalmitis (EFE) is a rare but sight- and life-threatening condition that often arises in immunocompromised patients. While Aspergillus fumigatus is the predominant pathogen, Aspergillus niger-associated endocarditis leading to bilateral EFE has not been previously reported. PATIENT CONCERNS: A 51-year-old woman with a history of two renal transplants over the past 30 years, along with diabetes mellitus, hypertension, and ongoing immunosuppressive therapy, presented with rapidly progressive bilateral visual impairment, beginning with acute vision loss and ocular pain in the right eye, followed by involvement of the left eye within two days. She had no systemic symptoms such as fever, chest pain, or dyspnea. DIAGNOSIS: Initial aqueous humor analysis, including Gram staining, fungal culture, and viral PCR, yielded negative results. As the disease progressed to bilateral involvement within 2 days, a diagnostic vitrectomy was performed. Vitreous sampling demonstrated fungal hyphae, and culture confirmed Aspergillus niger. Transesophageal echocardiography further revealed mitral valve vegetation, establishing the diagnosis of fungal infective endocarditis with bilateral endogenous endophthalmitis. INTERVENTIONS: The patient received empiric intravitreal antibiotics and antivirals initially, followed by diagnostic pars plana vitrectomy and systemic antifungal therapy after identification of Aspergillus. Mitral valve replacement surgery was subsequently performed. OUTCOMES: Despite surgical intervention and systemic antifungal treatment, the patient developed disseminated fungal sepsis and died 2 weeks after valve replacement. LESSONS: This case highlights the diagnostic challenges of EFE and emphasizes the importance of considering fungal endocarditis as a source of infection in immunosuppressed patients presenting with severe vitritis, even in the absence of systemic symptoms. Early recognition, prompt vitrectomy with intravitreal antifungal therapy, and thorough systemic evaluation are essential to improve visual and systemic outcomes.