Cryptococcus neoformans Infective Endocarditis After Lung Transplantation

Abstract

Cryptococcus neoformans infective endocarditis is rarely reported. In this report, we present a case of infective endocarditis secondary to C. neoformans in a lung transplant recipient and review the relevant literature. A 65-year-old man was hospitalized with hypoxemic respiratory failure and underwent left-sided single lung transplantation. In the setting of worsening hypoxemia, blood cultures were drawn, which grew C. neoformans. Lumbar puncture was performed, and cerebrospinal fluid (CSF) polymerase chain reaction (PCR) was also positive for Cryptococcus. Further exposure history revealed that he had raised chickens while living in Peru. Transesophageal echocardiography showed an aortic valve vegetation, and he was diagnosed with cryptococcal infective endocarditis. He received liposomal amphotericin B and flucytosine for 2 weeks and was later transitioned to fluconazole. This case highlights the need for thorough social history before lung transplantation, as pulmonary colonization with C. neoformans may result in infective endocarditis after immunosuppression.

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

“…First, emboli are more frequent in fungal IE compared to bacterial IE, and their occurrence might offer a clue. These emboli can be related to large fungal vegetations, which are friable and highly mobile [43,52,56,57,76,78,90,93,95,98,99] . Stroke was documented in 29 of the included cases, while splenic, renal, pulmonary, or peripheral embolism were documented in 20 cases.…”

“…Third, immune compromised conditions [71,83,107,120] , such as post-splenectomy [82] organ transplantation or malignancy [45,85,100,[112][113][114]117,122,125] , or need for steroids for other reasons [16,46,81,93] , also offer an indication. However, some immunocompetent patients could suffer from fungal IE [121] and risk factors may either be absent [99,101] or restricted to an indwelling urinary catheter [59,67] . Fourth, other clues can be IV drug use [40,55,57,61,66,73,74,92] , hemodialysis [16,94] , an earlier IE [56,61] , or extended treatment by antibiotics for other reasons [54,70,86,101] .…”

“…However, even repeated TEE can remain negative for some time [61] . Some echocardiographic features point to fungal IE, such as large vegetations [48,57,64,68,78,84,99] , obstruction of a valve prosthesis [42,51,73,105,123] , presence of fungal balls [76,91] , and mural, intracardiac and other non-valvular manifestations [79,81,82,85,99,112,113,114,120,122] . TEE increases the diagnosis in TTE-negative patients, but this invasive procedure carries the risk of embolization [38] .…”

“…A cardiac CT can be needed to demonstrate the vegetation or filling defect [123] or cardiac abscesses [85] . Cardiac MRI can sometimes be necessary for the distinction between invasive aspergilloma and a tumor of the heart [69,98,99] . CT/MRI of other regions is part of the work-up, especially in cases of stroke or infarctions and abscesses of other solid organs.…”