Fungal prosthetic aortic valve endocarditis and endarteritis: An unusual cause of aortic root vegetations

Abstract

Fungal endocarditis is a relatively rare occurrence with high morbidity and mortality. Patients may have an indolent and non‐specific course requiring a high index of suspicion to make a diagnosis. Here, we present the case of a 33‐year‐old patient who presented with fevers and acute lower limb ischemia requiring a 4‐compartment fasciotomy caused by septic emboli from Candida albicans endocarditis. The patient had a large vegetation in the ascending aorta associated with a mycotic aneurysm, which is an exceedingly rare location for a vegetation. We also review the literature and summarize the typical echocardiographic appearance and vegetation locations in fungal endocarditis.

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

“…In 86 reports, 91 cases of definitive fungal IE were described. These reports involved fifteen cases with Candida parapsilosis [40][41][42][43][44][45][46][47][48][49][50][51][52][53][54] , seven cases with C. albicans [55][56][57][58][59][60][61] , three cases with C. tropicalis [62][63][64] , eight other species with Candida [65][66][67][68][69][70][71][72] , eight cases with Candida with a bacterium [73][74][75][76][77][78][79][80] , ten cases with Aspergillus fumigatus [81][82][83][84][85][86][87][88][89]…”

“…In many cases with negative cultures or difficulties in identifying the infecting fungal microorganism, beta-D-glucan testing was performed. This was needed in a minority of Candida infections [51,54,55] but more often in Aspergillus [81,84,87,90,92,96] and certain other fungal species [101,106,107,118,[120][121][122][123][124] . Detection for the presence of galactomannan was also performed in IE by Aspergillus [85,89,92,93] and other uncommon species [112][113][114]120,121,125] .…”

“…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] . Last, a high index of suspicion for fungal IE should be maintained in patients with sepsis, negative blood culture before any antibiotic treatment, and known risk factors who do not respond well to broad-spectrum antibiotics.…”

“…Culturing fungi requires mediums rich in carbohydrates, nitrogen, and a pH of 5- [128] , but there is no "one size fits all" scenario. After discussion with clinical laboratory experts, serial blood testing or incubation for several weeks can be considered necessary since these organisms are fastidious [41,55,64,90,102,107,118] . So-called negative results should not be discarded [86,96,102,104] .…”

Fundamental role of echocardiographic evaluation in the diagnosis of prosthetic valve endocarditis

“…We have recently read with great interest the article by Carneiro et al entitled "Fungal prosthetic aortic valve endocarditis and endarteritis: An unusual cause of aortic root vegetations". 1 The authors reported a case of fungal aortic prosthetic valve endocarditis (PVE), which was successfully treated with antibiotic therapy plus surgical intervention. We congratulate the authors for achieving a successful outcome in such a high-risk patient.…”