Aspergillus infection in the ascending aorta of a patient with aortic and mitral valve prostheses

Abstract

We report the case of implantation of metallic mitral and aortic valve prostheses 6 months earlier, with subsequent multiple embolic episodes. The Although fungal infections occur more frequently in immunocompromised patients, several cases of this type of infection after cardiac surgery have been reported in the medical literature 1,2 . The incidence of infective endocarditis in valvar prostheses ranges from 7 to 25% 3-5 . The higherrisk period comprises the 6 months following valvar replacement, with an incidence of infective endocarditis ranging from 1.4 to 3.1% in the first year and decreasing to 0.35% after 1 year. The most common infective agents in the first 60 days following prosthesis implantation are Staphylococcus aureus, the gram negative bacilli, the diphtheroids, and fungi. Fungi may account for up to 10% of the cases, with a predominance of Candida albicans and Aspergillus sp 3,6 . The major predisposing factors for fungal infection are cardiac surgery, the use of intravenous drugs, prolonged intravenous antibiotic therapy, parenteral nutrition, and severe immunosuppression [1][2][3][4] . Systemic embolism, predominating in the brain, is a frequent complication in this type of infection and occurs in 22 to 50% of the cases 5 . Case reportThe patient was a 27-year-old white male, plumber, from the Brazilian State of Ceara, residing in the city of São Paulo, who underwent implantation of 2 metallic prostheses on 2/14/01. Six months later, the patient experienced an episode of acute arterial embolism in the left lower limb. The patient denied having fever and used oral anticoagulant agents regularly. His international normalized ratio was 3.0, and he underwent left infrapatellar popliteal thromboembolectomy. The thrombi had the gross appearance of clots and were not sent for anatomicopathological examination. The transesophageal echocardiography showed normofunctioning prostheses, spontaneous contrast medium (degree II) in the left atrium, and no intracavitary thrombi. After hospital discharge, the patient experienced a new episode of peripheral embolism and the anatomicopathological examination of the removed thrombi was compatible with mixed thrombi, focally organized, and negative for culture. The echocardiogram showed a sessile image adhered to the ascending aorta wall and projecting to the vessel lumen 1 cm away from the ring, suggestive of thrombosis. Anticoagulation was intensified and an antiplatelet agent was added. Three months later, the patient was hospitalized again with findings of arterial ischemia, an international normalized ratio of 5.4, and the anatomicopathological examination of the embolus showed fungal infection in recent thrombi, whose morphology was compatible with Aspergillus sp. The transesophageal echocardiogram showed normofunctioning prostheses and an image in the ascending aorta similar to that previously reported. The hemogram was as follows: hematocrit, 30%; hemoglobin, 10 g/L; leukocytes, 9000, with no left shift; hemosedimentation rate, 100 mm/1st hour; C-reactive...

Post-operative aspergillosis

“…summarises some clinical details for 124 patients with Aspergillus endocarditis or aortitis following heart surgery [4,8–91]. The median age of these patients was 43.5 (range 0.8–71) years.…”

Cardiac and vascular causes of persistent fever: A systematic review

“…Most cases of vascular graft infection caused by Aspergillus species are believed to originate from contamination by fungal spores during operation (Liu et al, 2015). In severely infected patients, therapy with intravenous amphotericin B was initiated and followed by oral itraconazole (100 mg/day) should be undertaken before surgical operation is performed (Ramos Ade et al, 2003). The surgical operation is determined by extent of aorta involvement, and postoperative antifungal therapy should be continued.…”

Update on invasive aspergillosis: clinical and diagnostic aspects

“…Aspergillus accounted for 26% of cases of infective endocarditis occurring within a month of transplantation [73]. It may affect native or prosthetic valves and has been described after valvular surgery, after drug abuse and in patients requiring ventricular assistance devices [74–78]. Diagnosis is extremely difficult, since blood cultures usually remain negative [79–82].…”