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

Background Mucorales endophthalmitis is rare, rapidly progressive, and vision-threatening. Diagnosis may be delayed when clinical findings are nonspecific and conventional microbiological tests are negative. Case presentation A 55-year-old immunocompetent woman developed endophthalmitis after plant-related penetrating ocular trauma. Although the acute presentation initially favored bacterial endophthalmitis, empirical treatment covered both bacterial and fungal etiologies because of the injury mechanism. Initial improvement after vitrectomy was followed by recurrent inflammation and newly developed filamentous material on the iris, prompting repeat surgery. Despite continued topical fluconazole and intraocular and intravenous voriconazole after repeat surgery, intraocular inflammation continued to progress. Both bacterial and fungal cultures remained negative, and no fungal elements were identified by direct microscopy; however, mNGS detected R. arrhizus in three separately collected intraocular specimens. Because fluconazole and voriconazole lack reliable activity against Mucorales, the antifungal regimen was immediately changed to intravenous liposomal amphotericin B and topical amphotericin B, after which the intraocular inflammation improved rapidly. Progressive renal impairment subsequently required transition from intravenous liposomal amphotericin B to oral isavuconazole after multidisciplinary consultation, while topical amphotericin B was continued. Intraocular inflammation remained controlled. At final follow-up, pinhole visual acuity was 20/160, although intraocular pressure remained low. Conclusion This case highlights the evolving course of trauma-associated fungal endophthalmitis and the need for prompt re-evaluation when progression deviates from expectations. In culture-negative infection, molecular findings should complement conventional microbiology to support timely pathogen-directed treatment. Close systemic monitoring and multidisciplinary treatment adjustment are essential to balance ocular infection control with systemic safety.