Unusual pharmacokinetics of intravitreal and systemic voriconazole in a patient with Scedosporium apiospermum endophthalmitis

In this paper, we report a case of a post-traumatic Scedosporium endophthalmitis treated with a posterior vitrectomy, followed by intravitreal injections and systemic voriconazole. This is the second documented case of S. apiospermum endophthalmitis treated with voriconazole and the first case with intravitreal injections of voriconazole. A 29-year-old man developed endophthalmitis after being struck in the left eye by a chip from a swimming pool pump. Despite 3 weeks of prophylactic antibiotherapy, his visual acuity remained only for the perception of light and vitreous inflammation increased. A creamy-white fungal mass grew at the inferior peripheral retina and pars plana. The fungus was identified as S. apiospermum. Oral voriconazole, at 200 mg twice-daily, did not bring the infection under control, considering the low plasma and intravitreal concentrations. Before steady-state plasma voriconazole concentrations reached an efficacy level greater than minimum inhibitory concentration of Scedosporium, intravitreal injections of 64 ug/0.1 mL of voriconazole were initiated twice-weekly for 3 weeks. Administration of higher intravenous voriconazole doses (6 mg/kg b.i.d.) for 6 weeks was needed to achieve an antifungal effect without systemic dissemination.