Clinical Profile of Prosthetic Valve Endocarditis due to Candida parapsilosis: An 11-year Retrospective Observational Study from a Quaternary Cardiac Referral Institute in India

Abstract

Background: Recent changes in the diagnostic criteria and the introduction of newer technologies like prosthetic valve replacement require the need to identify the changing epidemiology of prosthetic valve endocarditis (PVE). Materials and methods: This is a retrospective, cross-sectional, observational study. Patients diagnosed with Candida parapsilosis definite and possible PVE as per modified Duke’s criteria for a period of 11 years from January 2010 to December 2020 were included for the analysis. Results: Twelve of the 47 PVE cases (25.5%) were caused by C. parapsilosis . The median age of the patients was 52 years. Males were predominantly affected (58%). Based on the modified Duke’s criteria, eight (67%) were definite infective endocarditis (IE) cases. The single valve was affected in 11 cases (92%) with the mitral valve being the commonest ( n = 8, 67%). The type of valve commonly involved was mechanical [ n = 10, 83%]. The mean size of the vegetation was 13.15 mm. Most cases ( n = 7, 58%) were late-onset PVE. The mean C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and procalcitonin (PCT) levels for C. parapsilosis PVE were 70.2 mg/L, 51.08 mm/hour, and 0.3 ng/mL, respectively. The rates of complications and in-hospital mortality were 75% each. The most common observed complication was embolic events ( n = 8, 67%). Statistical significance ( p ≤ 0.05) was observed for mean vegetation size, overall complications, embolic events, and mortality for C. parapsilosis PVE when compared with bacterial PVE. Conclusion: C. parapsilosis was the commonest etiological agent causing PVE. Predominant mitral valve involvement, higher rates of late-onset presentation, complications, and mortality were key differential characteristics observed. Highlights: The manuscript throws light on the changing epidemiology, clinical, and microbiological profile of PVE due to Candida sp., which are scarcely studied and reported in low- and middle-income countries like India. How to cite this article: Ponnambath DK, Gopalakrishnan A, Pillai VV, Kaviyil JE, Raja K. Clinical Profile of Prosthetic Valve Endocarditis due to Candida parapsilosis : An 11-year Retrospective Observational Study from a Quaternary Cardiac Referral Institute in India. Indian J Crit Care Med 2021;25(8):860–865.

In vitro susceptibility profiles of Candida parapsilosis species complex subtypes from deep infections to nine antifungal drugs

“…One study showed that the mean age of Indian patients with infective endocarditis caused by C. parapsilosis sensu stricto was 52 years [25]. In eastern China, nearly twice as many men as women have been infected with C. parapsilosis sensu stricto in the past 15 years, with an average age of approximately 54 years [6].…”

“Not much room for mushrooms” in the heart: knowns and unknowns of fungal infective endocarditis

“…Thirty series could be identified. There is a large variation in the rates of fungal IE, which ranges from less than 1% [10][11][12][13][14][15][16] , between 1% and 2% [17][18][19][20][21][22][23][24][25][26][27][28][29] , between 2% and 5% [30][31][32][33][34] , to over 5% [35][36][37][38][39] . The latter series included patients with an immune compromised state such as after transplantation [36] or with prosthetic valves [38,39] .…”

“…Most authors group all fungal IE in one category [13,[15][16][17][18][19][20]29,30,32,[34][35][36] ; some only mention Candida ssp [10,15,[22][23][24]28] . or specify the Candida subspecies [11,21,37,39] , or group Candida together with Aspergillus [25] or focus on one specific agent such as Malassezia [33] .…”

First case report of Candida guilliermondii native left-sided valve endocarditis

“…The frequency of fungal native-valve endocarditis is largely unknown, however this disease affects nearly 0.1% of all prosthetic cardiac valves (9). Despite its rarity, Fungal endocarditis can present in any isolated heart valve or the combination of them (10)(11)(12)(13). Rising fungal endocarditis cases are attributed to improved diagnostic techniques, usage of immunosuppressants, invasive procedures, and the prevalent use of central venous catheters, which escalate the risk of medical-related IE.…”