대한안과학회지 2014 년제 55 권제 7 호 J Korean Ophthalmol Soc 2014;55(7):1106-1110 pissn: 0378-6471 eissn: 2092-9374 http://dx.doi.org/10.3341/jkos.2014.55.7.1106 Case Report 칸디다맥락망막염에합병된맥락막신생혈관에서유리체강내베바시주맙주입술치료 Intravitreal Bevacizumab Injection for the Treatment of Choroidal Neovascularization Secondary to Candida Chorioretinitis 이상협 이정욱 신용운 이병로 Sang Hyup Lee, MD, Jung Wook Lee, MD, Yong Un Shin, MD, PhD, Byung Ro Lee, MD, PhD 한양대학교의과대학한양대학교의대부속병원안과학교실 Department of Ophthalmology, Hanyang University Medical Center, Hanyang University College of Medicine, Seoul, Korea Purpose: To report a case of choroidal neovascularization (CNV) secondary to candida chorioretinitis initially treated with an intravitreal bevacizumab injection. Case summary: A 50-year-old female presented at our clinic with decreased vision and metamorphopsia in her left eye of 5 days duration. She received an anti-fungal treatment 2 months prior due to the presence of endogenous candida choroiditis in both eyes. Fluorescein angiography and optical coherence tomography (OCT) revealed juxtafoveal CNV in her left eye. Three monthly intravitreal injections of bevacizumab were administered as the initial loading dosage. Her visual symptoms improved and CNV regression was observed on OCT. No recurrence or complications were observed during the 6 month follow-up. Conclusions: Based on the present study results we suggest that intravitreal bevacizumab injection can be used to effectively treat CNV and improve visual symptoms during the treatment of juxtafoveal CNV associated with candida choroiditis. J Korean Ophthalmol Soc 2014;55(7):1106-1110 Key Words: Bevacizumab, Candida, Choroidal neovascularization, Choroiditis, Intravitreal injection 칸디다균은내인성안내염의주요한원인이며망막과맥락막의진균감염질환중칸디다맥락망막염이가장흔하다. 1 전신적인항진균제의투여가진균의박멸과염증감소에필수적이나항진균제치료가끝나도칸디다맥락막염에이차적으로맥락막신생혈관이발생하게되면시력은감소될수있다. 1,2 칸디다맥락막염에합병되는맥락막신생혈관 은활동성염증이해소된후관찰되는후기합병증으로대개맥락망막반흔에서발생한다. 맥락막신생혈관의치료로레이저광응고술이나망막하신생혈관복합체의수술적절제술, 광역동치료 (photodynamic therapy; PDT) 가제시되어왔다. 1-3 이에저자들은칸디다맥락염에이차적으로발생한맥락막신생혈관을유리체강내베바시주맙주입술로치료한사례를보고하고자한다. Received: 2013. 12. 7. Revised: 2014. 2. 17. Accepted: 2014. 6. 9. Address reprint requests to Byung Ro Lee, MD, PhD Department of Ophthalmology, Hanyang University Medical Center, #222 Wangsimni-ro, Seongdong-gu, Seoul 133-791, Korea Tel: 82-2-2290-8570, Fax: 82-2-2291-8517 E-mail: stynel@nate.com 증례보고 50세의여성이 5일전부터시작된양안의시력저하로안과에의뢰되었다. 환자는독성쇼크증후군으로감염내과에서입원치료중카테터관련감염이발생하였고과도한항생제사용으로혈액배양검사상 Candida albicans가동정되 c2014 The Korean Ophthalmological Society This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 1106
- 이상협외 : 칸디다맥락망막염과맥락막신생혈관 - A B C D E Figure 1. (A) A colored fundus photograph of a patient with endogenous Candida chorioretinitis showing multifocal yellow-white chorioretinal infiltrates in both the eyes. (B) Color fundus photographs after systemic anti-fungal therapy. A reduced number of multiple yellow-white infiltrates and some chorioretinal scars remained in both eyes. (C, D, E) Imaging studies of the patient who had a visual disturbance in the left eye two months after anti-fungal therapy administration. (C) Color fundus photograph showing subretinal hemorrhage and subretinal membrane temporal to the left fovea. (D) Fluorescein angiography demonstrates a late juxtafoveal leakage. (E) Subretinal fluid and a subretinal neovascular complex are visible on the spectral-domain optical coherence tomography image. 1107
- 대한안과학회지 2014 년제 55 권제 7 호 - A B Figure 2. (A) Color fundus and spectral-domain optical coherence tomography (OCT) images of the left eye of a patient treated with a single bevacizumab injection. Subretinal fluid and neovascular complex were not observed and only pigment epithelial detachment temporal to the fovea remained. Two additional monthly intravitreal bevacizumab injections were administered. (B) No recurrence or complications were observed on fundus photograph and OCT imaging during the eight-month follow-up. 었다. 최대교정시력검사상양안 20/40으로측정되었다. 세극등검사상전방과유리체는특이소견이없었으나, 안저검사상양안후극부에서다발성의노란색맥락망막병변이관찰되었다 (Fig. 1A). 안과적검사소견을바탕으로양안의내인성진균안내염을의심하였고, 정맥내 fluconazole 800 mg/day, ceftriaxone 2 g/day, clindamycin 2.4 g/day을 2주간주입하였다. 2주후최대교정시력은양안 20/25으로호전되었으며안저검사상노란색맥락망막병변의크기와수가감소하였다. 1주뒤환자는경구투여로항진균제를처방받고퇴원하였다. 1개월후양안모두염증징후는보이지않았으며좌안에서작은맥락망막반흔이관찰되었다 (Fig. 1B). 그러나퇴원 2달후환자는시력저하와변시증을호소하며내원하였고최대교정시력은우안 20/25, 좌안 20/100으로좌안의시력이감소되었다. 안저검사상맥락망막염의재발징후는보이지않았으나좌안의황반부에서융기된망막하병변이주변부출혈과삼출물과동반되어관찰되었다 (Fig. 1C). 빛간섭단층촬영 (OCT-2000, Topcon Corp., Japan) 검사상좌안의중심와망막하액을동반한맥락막신생혈관이, 형광안저촬영에서는좌안황반부의강한착색과후기형광누출 이확인되었고, 맥락막신생혈관은중심와의이측에위치한맥락망막반흔에서발생한것으로생각했다 (Fig. 1D, E). 칸디다맥락망막염의이차적으로발생한중심와곁맥락막신생혈관이진단된후곧바로유리체강내베바시주맙주입술 (1.25 mg/0.05 ml) 을시행하였다. 1개월후빛간섭단층촬영상맥락막신생혈관의퇴행과망막하액의소실이관찰되었으며시력증상이호전되었고, 최대교정시력은좌안 20/40으로상승하였다 (Fig. 2). 이후 1개월간격으로 2회의주입술을추가로시행하였으며 6개월간의추적관찰기간동안재발과합병증은관찰되지않았다. 좌안의최대교정시력은 20/30으로상승되었다. 고찰 항혈관내피세포성장인자 (anti-vascular endothelial growth factor; anti-vegf) 는연령관련황반변성 4 과병적근시, 5 후부포도막염, 6 안히스토플라스마증 (Presumed Ocular Histoplasmosis syndrome, POHS) 7,8 과같은감염질환등의다양한황반부질환에서이차적으로발생한맥락막신생혈관에효과적이고안전한치료방법으로널리알려졌다. 1108
- 이상협외 : 칸디다맥락망막염과맥락막신생혈관 - 본증례에서저자들은 PrONTO study 9 의규약을따라 1 개월마다 3회의연속적인베바시주맙주입술을시행후 (loading dose) 매달관찰하면서빛간섭단층촬영에서악화및재발이관찰될경우에만재치료를하였으며최대교정시력과망막하병변은처음베바시주맙주사후바로호전을보였다. Sheu 10 는내인성칸디다안내염에합병된맥락막신생혈관을 1회의유리체강내라니비주맙주사로치료하였으며 10개월간의경과관찰동안재발이없었던증례를보고한바가있으나, Ehrlich et al 7 은칸디다맥락막염과유사한임상증상을보인 POHS환자에서합병된맥락막신생혈관을 1회의베바시주맙으로치료후재발이발생한사례를발표하였다. 따라서저자들은맥락막신생혈관의조기재발을우려하여부하용량으로 1개월마다 3차례의베바시주맙을주사하였다. 레이저광응고술이나수술적치료는맥락막신생혈관의퇴행에효과적일수있겠으나일부소수의경우만이이치료를적용가능하며, 광역동치료 (PDT) 는 Tedeschi et al 3 이칸디다안내염환자의황반부맥락막신생혈관에서효과가있음을발표한바가있다. 그러나칸디다맥락망막염에의한이차적맥락막신생혈관은몇건의증례보고외에는발표된바가없어치료법간의비교가어렵다. 그러나 anti-vegf치료는칸디다맥락막염이나 POHS 같은감염질환에서이차적으로발병한맥락막신생혈관에빠르고효과적으로작용할수있으며특별한안구의합병증을동반하지않는다. 칸디다맥락막염에합병된맥락막신생혈관을유리체강내베바시주맙주사로치료한증례는이전에보고된바가없다. 본증례에서도 anti-vegf치료가다른이차성맥락막신생혈관의치료와같이효과적으로신생혈관의퇴행을유 도하며시각증상의호전을가져올수있었다. REFERENCES 1) Jampol LM, Sung J, Walker JD, et al. Choroidal neovascularization secondary to Candida albicans chorioretinitis. Am J Ophthalmol 1996;121:643-9. 2) Beebe WE, Kirkland C, Price J. A subretinal neovascular membrane as a complication of endogenous Candida endophthalmitis. Ann Ophthalmol 1987;19:207-9. 3) Tedeschi M, Varano M, Schiano Lomoriello D, et al. Photodynamic therapy outcomes in a case of macular choroidal neovascularization secondary to Candida endophthalmitis. Eur J Ophthalmol 2007; 17:124-7. 4) CATT Research Group. Ranibizumab and bevacizumab for neovascular age-related macular degeneration. N Engl J Med 2011; 364:1897-908. 5) Ruiz-Moreno JM, Montero JA. Intravitreal bevacizumab to treat myopic choroidal neovascularization: 2-year outcome. Graefes Arch Clin Exp Ophthalmol 2010;248:937-41. 6) Julian K, Terrada C, Fardeau C, et al. Intravitreal bevacizumab as first local treatment for uveitis-related choroidal neovascularization: long-term results. Acta Ophthalmol 2011;89:179-84. 7) Ehrlich R, Ciulla TA, Maturi R, et al. Intravitreal bevacizumab for choroidal neovascularization secondary to presumed ocular histoplasmosis syndrome. Retina 2009;29:1418-23. 8) Schadlu R, Blinder KJ, Shah GK, et al. Intravitreal bevacizumab for choroidal neovascularization in ocular histoplasmosis. Am J Ophthalmol 2008;145:875-8. 9) Lalwani GA, Rosenfeld PJ, Fung AE, et al. A variable-dosing regimen with intravitreal ranibizumab for neovascular age-related macular degeneration: year 2 of the PrONTO Study. Am J Ophthalmol 2009;148:43-58.e1. 10) Sheu SJ. Intravitreal ranibizumab for the treatment of choroidal neovascularization secondary to endogenous endophthalmitis. Kaohsiung J Med Sci 2009;25:617-21. 1109
- 대한안과학회지 2014 년제 55 권제 7 호 - = 국문초록 = 칸디다맥락망막염에합병된맥락막신생혈관에서유리체강내베바시주맙주입술치료 목적 : 칸디다맥락망막염환자에서발생한맥락막신생혈관을유리체강내베바시주맙주입술을초기치료로사용하여효과적으로치유된증례에대해보고하고자한다. 증례요약 : 50 세의여성이 5 일전부터발생한좌안의시력저하와변시증을주소로내원하였다. 환자는 2 달전양안의내인성칸디다맥락망막염으로항진균제치료를받은과거력이있었다. 형광안저촬영과빛간섭단층촬영에서좌안의중심와곁맥락막신생혈관이확인되었다. 3 회의유리체강내베바시주맙주입술을시행하였고시각증상이호전되었으며빛간섭단층촬영상맥락막신생혈관의퇴행이관찰되었다. 6 개월간의경과관찰동안재발과합병증은관찰되지않았다. 결론 : 칸디다맥락망막염과관련된맥락막신생혈관에서유리체강내베바시주맙주입술은효과적으로신생혈관의퇴행을유도하며시각증상의호전을가져올수있다. < 대한안과학회지 2014;55(7):1106-1110> 1110