면역저하 환자에서 진균성 대뇌 동맥류를 동반한 안내염 1예
A Case of Endogenous Aspergillus Endophthalmitis Associated with Mycotic Cerebral Aneurysm
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목적: 면역저하 환자의 내인성 Aspergillus 안내염 치료 중 진균성 대뇌 동맥류가 동반된 환자 1예를 보고하고자 한다. 증례요약: 51세 여자가 10일 전부터 시작된 좌안 시력저하를 주소로 안과에 의뢰되었다. 안과내원 1달 전에 간 이식 수술을 시행 받았으며 고열과 간수치 상승으로 내과에 입원 중이었다. 좌안에 심한 전방세포 소견과 안저에 심한 유리체 혼탁과 망막하 농양이 관찰되었다. 혈액 검사상 Aspergillus 항원 양성 이외 특이 소견은 없었다. 좌안 유리체절제술, 항생제 주입술, 배양검사 시행하였다. 수술 후염증 소견은 호전되었다. 그러나 수술 3주 뒤, 갑작스런 좌측 손과 발의 편마비가 발생하였다. 뇌 컴퓨터단층촬영에서 우측 대뇌반구출혈이 관찰되었고 뇌자기공명혈관조영에서 진균성 동맥류가 발견되었다. 환자는 즉시 동맥류 색전술을 시행 받았으며 심각한 후유증을 남기지 않고 회복되었다. 진균성 동맥류와 혈청검사 결과를 토대로 내인성 Aspergillus 안내염을 진단할 수 있었다. 결론: 면역저하환자에서 원인불명의 안구내염 치료 시, 진균성 뇌동맥류의 가능성도 있을 수 있으므로 세심한 검사가 필요할 것으로생각한다.
Abstract
Purpose: To report a case of a endogenous Aspergillus endophthalmitis associated with mycotic cerebral aneurysmal rupture. Case summary: A 51-year-old woman was referred to our retina clinic for decreased visual acuity in the left eye. The patient had previously undergone a liver transplant for liver cirrhosis and hepatocellular carcinoma. On fundus examination,vitreous opacities with a yellowish-white subretinal abscess were observed. There were no abnormal findings except the positive sign in the laboratory serum Aspergillus antigen test performed on admission. Based on the suspicion of endogenous endophthalmitis, pars plana vitrectomy was performed with intravitreal antibiotics injection to treat fungal and bacterial infections. There was no growth in either the vitreous or anterior chamber culture. After vitrectomy,visual acuity improved and the inflammation subsided. However, by the three-week follow-up, acute-onset left hemiplegia with a right hemisphere cerebral hemorrhage had occurred. Cerebral magnetic resonance angiography showed multiple mycotic aneurysms characterized by a large and fusiform appearance. The patient was treated with neuro-embolization and was stabilized with minimal sequalae. Conclusions: Although the immunocompromised endophthalmitis patient can be treated using proper management, brain lesions such as mycotic aneurysm may exist and should be carefully considered.
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