“String‐of‐pearls”

A 41-year-old intravenous drug user (IVDU) was admitted with candidal endophthalmitis 6 weeks after a hospitalization for pneumonia. After discharge from his previous hospitalization which were blood cultures grew Candida albicans, attributed to contamination by a covering physician. The patient described ‘‘looking through spider webs.’’ Fundoscopic examination revealed fluffy, white ‘‘string-of-pearls’’ opacities with retinal obscuration (Fig. 1). There were no findings of endocarditis (negative echocardiogram) or congestive heart failure. Blood and vitreal cultures grew Candida albicans. The patient underwent a pars plana vitrectomy, and was prescribed chronic fluconazole. He was lost to follow-up. Candida albicans is the most common organism identified in endogenous endophthalmitis. Predisposing factors include IVDU, indwelling catheters, endocarditis, recent surgeries, immunosuppression, broad-spectrum antibiotics, and parental nutrition. The diagnosis is based on retinal findings of white pinpoint opacities (string-of-pearls, Fig. 2), with vitreous involvement and positive cultures. Endocarditis occurs in 15%–17% of patients with endophthalmitis. This case highlights the importance of physician recognition of the significant attributable morbidity and mortality of candidemia.