A 55-year-old immunocompetent woman developed endophthalmitis following plant-related penetrating ocular trauma, presenting an evolving clinical course of fungal infection that required sequential multidisciplinary treatment adjustments. Although the initial acute presentation favored bacterial endophthalmitis, empirical therapy was initiated to cover both bacterial and fungal etiologies due to the specific mechanism of the injury.

Following an initial vitrectomy, the patient experienced temporary clinical improvement, but intraocular inflammation subsequently recurred alongside newly developed filamentous material on the iris. This recurrence prompted repeat surgery. Despite continued administration of topical fluconazole as well as intraocular and intravenous voriconazole after the second procedure, the intraocular inflammation continued to progress.

Standard diagnostic investigations proved inconclusive, as direct microscopy failed to identify fungal elements and both bacterial and fungal cultures remained negative. However, metagenomic next-generation sequencing successfully detected Rhizopus arrhizus across three separately collected intraocular specimens. As noted in the report, Mucorales endophthalmitis is rare, rapidly progressive, and vision-threatening, with diagnosis frequently delayed when clinical features are nonspecific and conventional microbiological tests yield negative results.

Because fluconazole and voriconazole lack reliable activity against Mucorales, the clinical team immediately transitioned the patient to intravenous liposomal amphotericin B and topical amphotericin B, leading to rapid improvement of the intraocular inflammation. When progressive renal impairment subsequently developed during therapy, a multidisciplinary consultation prompted a switch from intravenous liposomal amphotericin B to oral isavuconazole while maintaining topical amphotericin B.

Under the revised regimen, intraocular inflammation remained controlled throughout the remaining treatment period. At the final follow-up evaluation, the patient achieved a pinhole visual acuity of 20/160, although intraocular pressure remained low. The authors concluded that trauma-associated fungal endophthalmitis demands prompt re-evaluation when clinical trajectories deviate from expectations, emphasizing the role of molecular testing in culture-negative cases and the necessity of multidisciplinary coordination to balance ocular disease control with systemic drug safety.

The clinical course illustrates the specific diagnostic challenges associated with fungal endophthalmitis following penetrating ocular trauma. In this patient, plant-related trauma prompted empirical therapy covering both bacterial and fungal etiologies, even though the acute presentation initially favored a bacterial process. Diagnostic confirmation proved challenging because conventional microbiological evaluations remained completely negative. Direct microscopy revealed no fungal elements, and both bacterial and fungal cultures showed no growth. Because Mucorales endophthalmitis is rare, rapidly progressive, and vision-threatening, non-specific clinical presentations combined with negative standard microbiology frequently lead to delayed identification. In such culture-negative infections, relying solely on standard microbiological testing can hinder timely diagnosis as the clinical trajectory evolves.

Surgical and medical interventions required sequential re-evaluation as intraocular disease progressed. Although vitrectomy initially yielded improvement, the subsequent appearance of newly developed filamentous material on the iris alongside recurrent inflammation prompted repeat surgery. Intraocular inflammation continued to advance despite the continued administration of topical fluconazole as well as intravenous and intraocular voriconazole. This lack of response aligned with the known limitation that fluconazole and voriconazole lack reliable activity against Mucorales. Molecular testing resolved the diagnostic uncertainty when metagenomic next-generation sequencing detected Rhizopus arrhizus across three separately collected intraocular specimens. This identification demonstrated how molecular diagnostics can complement conventional microbiology to establish timely pathogen-directed treatment when standard cultures fail to isolate an organism.

Pathogen identification enabled rapid therapeutic realignment, which was immediately initiated with topical amphotericin B and intravenous liposomal amphotericin B. Intraocular inflammation improved rapidly following this change. When progressive renal impairment subsequently developed, multidisciplinary consultation guided treatment modification to protect systemic function. Intravenous liposomal amphotericin B was replaced with oral isavuconazole, while topical amphotericin B was continued. Under this coordinated regimen, intraocular inflammation remained controlled. At the final follow-up evaluation, pinhole visual acuity was 20/160, although intraocular pressure remained low. The reported findings highlight the evolving nature of trauma-associated fungal endophthalmitis, showing that deviation from expected clinical courses demands prompt re-evaluation, close systemic monitoring, and multidisciplinary treatment adjustments to balance ocular infection control with systemic safety.

Subject of Research: Trauma-associated Rhizopus arrhizus endophthalmitis diagnosis and management

Article Title: Trauma-associated Rhizopus endophthalmitis with an evolving clinical course in an immunocompetent patient: a case report

Article References: Wang, H., Wang, Y., Zhang, A., Ao, S., Yuan, Y., Song, Y., Wang, X., & Wang, S. (2026). Trauma-associated Rhizopus endophthalmitis with an evolving clinical course in an immunocompetent patient: a case report. BMC Ophthalmology. https://doi.org/10.1186/s12886-026-05471-8

Image Credits: AI Generated

DOI: 10.1186/s12886-026-05471-8

Keywords: Rhizopus arrhizus, endophthalmitis, fungal eye infection, ocular trauma, metagenomic next-generation sequencing, liposomal amphotericin B, isavuconazole, case report, Trauma-associated, Rhizopus, evolving, clinical