Human MRSA Isolates with Novel Genetic Homolog, Germany

30%–50% of immunosuppressed patients with coccidioidomycosis (3). Disseminated coccidioidomycosis typically involves the skin, meninges, or bone (3); however, intraocular involvement has also been described (1). A review of the literature shows 25 reported cases of intraocular coccidioidomycosis. When present, intraocular involvement is associated with serious consequences, frequently leading to eye enucleation; 1 case series described eventual enucleation in 50% of reported patients who did not die from disseminated coccidioidal infection (2). For the patient in our report, in the setting of reported trauma and negative metastatic work-up results, it is unclear whether ocular disease resulted independently as an exogenous infection or from endogenous lymphatic and/ or hematogenous spread from the patient’s lung. Diagnosis of coccidioidal endophthalmitis can be diffi cult, often relying on serum or nonocular tissue evaluation (4). Intraocular coccidioidal involvement usually occurs with widespread infection (5). Thus, even with apparent isolated ocular fi ndings, evaluation for disseminated disease is warranted, including a careful history and physical examination, CT chest scan, bone scan, intracranial imaging, and lumbar puncture. Evaluation for immunosuppression, including HIV status, is warranted. The optimal systemic antifungal therapy for intraocular coccidioidal infection is unclear, although fl uconazole is the drug of choice for extrapulmonary coccidioidomycosis, including meningitis (3). Fluconazole has good ocular penetration; however, voriconazole also achieves excellent intraocular levels (6) at lower 90% minimum inhibitory concentration levels (7). Furthermore, Gabrielian and Hariprasad (8) described an immunocompetent patient with treated and stable nonocular disseminated coccidioidomycosis who showed development of new vitritis and choroiditis 8 weeks into high-dose fl uconazole therapy; his intraocular disease resolved within 2–4 weeks of transition to voriconazole. The patient in our report received systemic voriconazole for 4 weeks plus repeated intravitreal voriconazole injections on follow-up. It is possible that this initial therapy had an effect on his positive outcome and the avoidance of eye enucleation. The optimal length of therapy is unclear; however, this patient will receive prolonged treatment (>1 year) with high-dose fl uconazole, followed by a slow taper guided by serologic testing and regular ophthalmologic examination. Future research should evaluate which antifungal therapy is superior and the appropriate duration of treatment.