Endophthalmitis and Lumbar Diskitis Due to Acremonium falciforme in a Splenectomized Patient

Bone infections caused by Acremonium species are uncommon, and, to our knowledge, there have been no reports of sequential acremoneium bone infections at two distant sites. We describe a patient who had previously undergone splenectomy who spontaneously developed acremonium endophthalmitis followed by diskitis of the lumbar spine. A 62-year-old man underwent a right carotid endarterectomy on 25 January 1993 because of symptoms of stenosis; in 1991 he had undergone nephrectomy and splenectomy for renal cell carcinoma. He was rehospitalized on 4 February with a 1-day history of pain and decreased vision in the right eye, which were unresponsive to treatment with eye drops containing cortisone and atropine. There was no history of direct trauma to the eye or of intravenous drug abuse. Examination revealed that the pupil of the right eye was dilated and nonreactive, the cornea was mildly edematous, and the anterior chamber was deep with 4+ cells, preventing visualization of the fundus. Specimens from the aqueous and vitreous chambers were obtained for culture, and gentamicin and vancomycin were injected into both the vitreous and the subconjunctival space. A three-port trans—pars plana vitrectomy was performed to obtain a vitreous specimen and to partially remove debris. Vancomycin and gentamicin were again injected into the vitreous, and gentamicin was given intravenously from 5 February to 8 February 1993. The vitreous cultures yielded an unidentified fungus, and on 7 February treatment with intravenous and intraocular amphotericin B was begun. On 11 February, the fungus was identified as an Acremonium species. Because the infection appeared to be unresponsive to therapy, the involved eye was removed. On 13 February, amphotericin B therapy was discontinued when the patient developed renal dysfunction after receiving a total dose of 121 mg. He was discharged on 16 February. Two cultures of anterior chamber fluid were both negative, but cultures of specimens from the posterior chamber of the eye were positive for Acremonium falciforme. Pathological examination of the enucleated eye revealed fungal elements in the rear of the posterior chamber and in the anterior portion of the vitreous. Blood cultures were negative. One month later, the patient noted the gradual onset of intermittent midline lower back pain. Because of this pain, he was rehospitalized 4 months later; a bone scan revealed an abnormality in the L4—L5 interspace. End-plate erosion and diskitis at L4—L5 were identified on roentgenograms and an MRI. On 15 July 1993 yellow fluid devoid of WBCs was found during L4—L5 microdiskectomy. No organisms were seen on gram staining. Cultures of the fluid and surgical samples yielded A. falciforme. The erythrocyte sedimentation rate (Westergren method) was 85 mm/h. The patient was treated with oral fluconazole and amphotericin B (total dose, 336 mg) from 21July until 17 August, when