Clinical features, diagnosis and treatment outcome of fungal endocarditis: A systematic review of reported cases.

The landscape of fungal endocarditis (FE) has constantly been evolving in the last few decades. Despite the advancement in diagnostic methods and the introduction of newer antifungals, mortality remains high in FE. This systematic review aimed to evaluate the epidemiology, clinical features, diagnostic and therapeutic interventions in patients with FE. We also aim to examine the aforementioned factors as a determinant of mortality in FE. A literature search was performed in PubMed, Google Scholar and Scopus, and all patients ≥18 years with proven fungal endocarditis were included. A total of 220 articles (250 patients) were included in the final analysis. Candida was the commonest aetiology (49.6%), followed by Aspergillus (30%) and Scedosporium species (3.2%). The proportion of prosthetic valve endocarditis (PVE) and intravenous drug users was 35.2% and 16%, respectively. The overall mortality rate was 40%. On multivariate analysis, Aspergillus endocarditis (HR 3.7, 95% CI 1.4-9.7; p = .009) and immunocompromised state (HR 2.8, 95% CI 1.24-6.3; p = .013) were independently associated with mortality. Patients treated with surgery along antifungals had better survival (HR 0.20, 95% CI 0.09-0.42; p < .001) compared to those treated with antifungals alone. Recurrence of FE was reported in 10.4% of patients. In conclusion, FE carries significant mortality, particularly in immunodeficient and Aspergillus endocarditis. We advocate the use of surgery combined with antifungals to improve clinical outcomes.

Sars-Cov-2 infection as a possible risk factor for prosthesis endocarditis: A challenging redo-Bentall for subvalvular abscess.

BACKGROUND: Candida Parapsilosis is an unusual agent of prosthetic endocarditis in immunocompetent individuals but Coronavirus disease 2019 is reported to be associated with a transient immunodeficency that exposes patientes to opportunistic infections. CASE REPORT: We describe a dreadful case of Candida Parapsilosis endocarditis in a transient immunosuppressed patient recently infected with severe acute respiratory syndrome-Coronavirus 2019. CONCLUSION: Considering that the symptoms of Candida Parapsilosis infection and the symptoms of Coronavirus disease-2019 may overlap, it is important never to understimate the non-specific symptoms to improve patient outcome, especially in patient with previous Coronavirurs disease-2019 infection and with prosthetic material grafting.

Malassezia restricta: An Underdiagnosed Causative Agent of Blood Culture-Negative Infective Endocarditis.

BACKGROUND: Infective endocarditis (IE) is a severe disease requiring microbial identification to successfully adapt its treatment. Currently, identification of its etiological microorganism remains unresolved in 5.2% of cases. We aimed to improve IE diagnosis using an ultra-sensitive molecular technique on cardiac samples in microbiologically nondocumented (culture and conventional polymerase chain reaction [PCR]) IE (NDIE) cases. METHODS: Cardiac samples explanted in a tertiary hospital in Lyon, France, from patients with definite IE over a 5-year period were retrospectively analyzed. NDIE was defined as Duke definite-IE associated with negative explorations including cardiac samples culture, bacterial amplification, and serologies. Ultrasensitive molecular diagnosis was achieved using the Universal Microbe Detection kit (Molzym®). Fungal identification was confirmed using 26S-rDNA and internal transcribed spacer amplifications. Fungal infection was confirmed using Grocott-Gromori staining, auto-immunohistochemistry on cardiac samples, and mannan serologies. RESULTS: Among 88 included patients, microbial DNA was detected in all 16 NDIE cases. Bacterial taxa typical of IE etiologies were detected in 13/16 cases and Malassezia restricta in the 3 other cases. In these 3 cases, histological examination confirmed the presence of fungi pathognomonic of Malassezia that reacted with patient sera in an auto-immunohistochemistry assay and cross-reacted with Candida albicans in an indirect immunofluorescent assay. CONCLUSIONS: M. restricta appears to be an underestimated causative agent of NDIE. Importantly, serological cross-reaction of M. restricta with C. albicans may lead to its misdiagnosis. This is of major concern since M. restricta is intrinsically resistant to echinocandins; the reference treatment for Candida-fungal IE.

All that attaches to atrial septum is not myxoma: deception is everywhere!

Preterm neonates - especially those with prolonged duration of intensive care stay - are prone to develop fungal endocarditis. Majority of these children have a stormy course, however, a few may be relatively asymptomatic. Occasionally these vegetations may be large and pedunculated, originating from the atrial septum, mimicking a cardiac myxoma on echocardiography.

Cryptococcus endocarditis: A case report and review of the literature.

INTRODUCTION: Cryptococcus neoformans is known to be a cause of meningitis. However, as cryptococcal endocarditis is rare, it is not well understood. Here, we describe a case with Implantable Cardioverter Defibrillator associated endocarditis and meningitis caused by Cryptococcus neoformans and we review the literature associated cryptococcal endocarditis. CASE PRESENTATION: A 72 years old Japanese male presented in emergency department with non-productive cough and respiratory discomfort. His past medical history was ischemic heart disease four years ago and ICD was implanted. Physical examination was unremarkable. Chest computer tomography revealed ground glass opacity in the right lung. He received a diagnosis of amiodarone-induced interstitial pneumonitis and high dose steroid pulse therapy. Septic shock and acute respiratory failure occurred after steroid therapy. Cryptococcus neoformans was identified by blood culture and cerebral spinal fluid. Intravenous liposomal Amphotericin B and oral flucytosine were initiated. Transesophageal echocardiography revealed vegetation on the lead of the ICD. Diagnosis of cryptococcal endocarditis was made. The patient died despite antifungal therapy was continued. DISCUSSION: We analyzed our case and 8 cases of cryptococcal endocarditis in the literature for 40 years. Almost all of the patients had previous valve replacement surgery or immunocompromised state. Three cases had meningitis. Surgery performed in 3 cases. The overall mortality rate were 44.4%. CONCLUSIONS: Cryptococcal endocarditis is rare and carries a high mortality. Almost all of the patients had underlying diseases. Diagnosis needs repeating blood culture and echocardiogram, sometimes. Cryptococcal endocarditis needs lumber puncture for rule out meningitis.

Fungal endocarditis after transcatheter aortic valve replacement (TAVR): Case report and review of literature.

The reported number of transcatheter aortic valve replacement-associated infective endocarditis (TAVR-IE) cases has been increasing worldwide, but information about the incidence and clinical features of fungal TAVR-IE is quite limited. We present a patient who acquired TAVR-IE caused by Candida parapsilosis four month after TAVR, who was successfully treated redo-aortic valve replacement and prolonged antifungal therapy.

Treatment of neonatal fungal infective endocarditis with recombinant tissue plasminogen: activator in a low birth weight infant case report and review of the literature.

With advances in medical sciences, an increase in survival rates of low birth weight; increased incidence in use of catheter and antibiotics, and total parenteral nutrition are reported, therefore, the rate of fungal infections in late and very late onset neonatal sepsis have increased. Although fungal endocarditis rarely occur in newborns, it has a high morbidity and mortality. Antifungal therapy is often insufficient in cases who develop fungal endocarditis and surgical treatment is not preferred due to its difficulty and high mortality. Herein, fungal endocarditis in a preterm newborn treated with single-dose recombinant tissue plasminogen activator in addition to antifungal therapy is presented and relevant literature has been reviewed. The vegetation completely disappeared following treatment and no complication was observed.

Evaluation of noninvasive methods for the diagnosis of fungal endocarditis.

Fungal endocarditis (FE) is an uncommon disease with a high risk of morbidity and mortality. Here, we evaluated the different methods for diagnosing this infection. Cardiac valve, vegetation, and embolic materials obtained during surgery were examined for fungal infections by direct smear and culture. At least two blood samples were inoculated at the bedside into BACTEC medium. Galactomannan, mannan Ag enzyme-linked immunosorbent assay, and real-time polymerase chain reaction (PCR) assay were performed with serum samples. Of 25 patients with suspected infective endocarditis (IE), 8 were found to have proven FE according to the direct culture results. The etiologic agents were Aspergillus niger (three cases), A. flavus (two cases), A. fumigatus (one case), and Candida albicans (two cases). Blood culture was positive in only 1 case. The sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of the results from the galactomannan test were 83.3%, 84.2%, 62.5%, 94.1%, 5.3, and 0.2; these same values, obtained from real-time PCR, were 87.5%, 94.4%, 87.5%, 94.4%, 15.6, and 0.14, respectively. Because mannan antigen was positive in samples from only one patient, we opted not to calculate the sensitivity. However, the specificity value in 23 cases without IE caused by Candida spp. was 100%. Based on our results, both the galactomannan test and real-time PCR can serve as reliable, noninvasive tests for the diagnosis of FE, compared with culture, which is considered to be the gold standard.

Aspergillus endocarditis.

Aspergillus endocarditis is a rare cause of fungal endocarditis caused by the hyaline mold Aspergillus. The disease most commonly occurs in persons who are immunosuppressed and has a high mortality. Clinical presentation is often with long standing fever, embolic manifestations, and often heart murmurs. Diagnosis of aspergillus endocarditis is often delayed due to the low propensity for Aspergillus to grow in blood culture. Aspergillus endocarditis is characterized by large vegetations and also by frequently being found on the walls of the heart and not on the valves and hence can be missed if not carefully looked for. Definitive diagnosis is often by a combination of microbiological culture and histopathological examination of obtained tissue. Ancillary serological tests like galactomannan assay and polymerase chain reaction also help in the diagnosis. Treatment of aspergillus endocarditis virtually always requires a combination of prolonged antifungal therapy and surgery to enable a cure for these patients.

Devastating fungal endocarditis involving ascending aorta in a patient with a history of aortic valve replacement: a case report.

BACKGROUND: Fungal endocarditis is a rare but serious condition associated with high mortality rates. Various predisposing factors contribute to its occurrence, such as underlying cardiac abnormalities, cardiac surgeries, prosthetic cardiac devices, and central venous catheters. Diagnosing fungal endocarditis, particularly Aspergillus, poses challenges, often complicated by negative blood cultures. CASE PRESENTATION: This report details a case of extensive ascending aorta involvement in Aspergillus endocarditis (AE) in a 24-year-old man with a history of bioprosthesis aortic valve replacement (AVR). Three months post-AVR, he presented with pericardial effusion and aortic rupture, leading to a redo biological valved conduit aortic root replacement (Bentall surgery). Despite the intervention, the tubular graft exhibited extensive Aspergillus involvement, resulting in graft disruption and significant peri-aortic infection. A second redo procedure involving aortic homograft root replacement was performed. Unfortunately, the patient succumbed two days after the surgery. CONCLUSION: A combined approach of medical and surgical therapies is recommended to manage fungal endocarditis. Despite efforts, the mortality rate associated with Aspergillus endocarditis remains unacceptably high, with no significant difference observed between combination therapy and antifungal treatment alone. Further research is essential to explore novel therapeutic strategies and improve outcomes for patients with this challenging condition.

Long-term survival following medical management of Aspergillus endocarditis with dissemination as a consequence of steroid therapy in severe COVID-19 pneumonia.

A male in his 40's with no known comorbidities developed severe COVID-19 pneumonia and received a four-week course of methylprednisolone. The patient subsequently developed disseminated Aspergillus endocarditis, manifesting as multiple organ involvement including the heart, eyes, and brain. Despite the poor prognosis generally associated with fungal endocarditis, the patient survived following aggressive medical management with a combination of liposomal amphotericin b and voriconazole therapy and is now doing well for over two years and is off antifungal therapy for a year.

Native Aortic Valve Endocarditis Caused by Scopulariopsis Species: Case Report, Considerations for Management, and Review of Literature.

We present the first case of native aortic valve endocarditis caused by Scopulariopsis. Intraoperative images and videos from valve replacement surgery illustrate the severity of fungal endocarditis. This case demonstrates the aggressive presentation of left-sided fungal endocarditis, highlights challenges with treating highly resistant fungi, and considers the potential utility of olorofim.

Blastomycosis Endocarditis: Case Report and Literature Review.

We report successful treatment of a case of disseminated blastomycosis originating in the right lung, with involvement of the right pleural space, multiple ribs and vertebral bodies, and the pericardium and mitral valve endocarditis. The 22-year-old patient presented with a 13-month history of right lower lobe pneumonia associated with fevers, night sweats, rib pain, and 27-kg weight loss. Pathology examination revealed Blastomyces from multiple biopsies of inflammatory masses in the right thorax. After a 4-week induction with liposomal amphotericin followed by oral itraconazole, the patient had complete resolution of the clinical and laboratory findings of blastomycosis.

Rare case of infective endocarditis from invasive aspergillosis encasing the pulmonary valve: a case report.

Background: Aspergillus endocarditis is a rare cause of infective endocarditis and requires high index of suspicion for diagnosis. Case summary: We describe a case of a 50-year-old man with history of metastatic thymoma on immunosuppression (gemcitabine and capecitabine) who presented with progressive dyspnoea. Echocardiography and computed tomography (CT) of chest showed filling defect in the pulmonary artery. The initial differential diagnosis was of pulmonary embolism and metastatic disease. The mass was subsequently excised, which revealed a diagnosis of Aspergillus endocarditis of the pulmonary valve. Unfortunately, he passed away despite medical treatment with antifungal therapy after surgery. Discussion: Aspergillus endocarditis should be suspected in immunosuppressed hosts with negative blood cultures and large vegetations on echocardiography. Diagnosis is made by tissue histology but may be difficult or delayed. Optimal treatment involves aggressive surgical debridement and prolonged antifungal therapy; prognosis is poor with high mortality.

Does Heart Failure Mask Candida Tricuspid Endocarditis?

Infective endocarditis (IE) carries high morbidity and mortality. Although minimal in incidence, fungal causes (mostly Candida species) carry the highest mortality among all cases of infective endocarditis. We describe a rare case of a 47-year-old male with a past medical history of cerebral vascular accident (CVA), heart failure with reduced ejection fraction status post (SP) automated implantable cardioverter defibrillator (AICD) placement, paroxysmal atrial fibrillation, coronary artery disease (CAD), infective endocarditis with mitral valve replacement and tricuspid valve replacement, and pulmonary hypertension who presented to the emergency department (ED) with complaints of shortness of breath and weakness for four days. The patient was admitted to the cardiac care unit (CCU) due to persistent hypotension despite being on a continuous milrinone drip at home. The patient was initially started on antimicrobial agents for sepsis most likely secondary to pneumonia. Echocardiographic imaging showed a large vegetation on the tricuspid valve; hence, blood cultures were sent and came back positive for Candida sp. Appropriate antifungals (micafungin) were added to the medication regimen, and the patient was transferred to a tertiary hospital for surgical intervention. Patients with bioprosthetic valve replacement require regular follow-ups as this would allow providers to catch symptoms of developing endocarditis and prevent disease progression. These appointments may also decrease other risk factors for the disease, including but not limited to infected lines.

Surgical Considerations for Treatment of Fungal Homograft Endocarditis in Re-re-re-re-do.

Fungal endocarditis is associated with high surgical mortality rates. Advanced expertise is required for surgical treatment of this serious condition. In the present report, we describe the homograft replacement in a beating heart during re-re-re-re-do in a 29-year-old female patient with fungal endocarditis. The previous operations included Fallot correction at the age of 1 year, Contegra graft implantation in the right ventricular outflow tract (RVOT) due to severe pulmonary insufficiency, homograft implantation in pulmonary position due to Contegra endocarditis, and on-pump pericardial defect closure after homograft injury during sternal rewiring following wound infection.

Candida endocarditis: Update on management considerations.

The rise in incidence rates of invasive candidiasis warrants an increase in attention and efforts toward preventing and treating this virulent infection. Cardiac involvement is one of the most feared sequelae and has a poor prognosis. Despite the introduction of several novel antifungal agents over the past quarter century, complications and mortality rates due to Candida endocarditis have remained high. Although fungal endocarditis has a mechanism similar to bacterial endocarditis, no specific diagnostic criteria or algorithm exists to help guide its management. Furthermore, recent data has questioned the current guidelines recommending a combined approach of antifungal agents with surgical valve or indwelling prostheses removal. With the emergence of multidrug-resistant Candida auris, a focus on improved prophylactic measures and management strategies is necessary.

Fungal Endocarditis Secondary to Transdermal Fentanyl Patch.

Fungal endocarditis is an uncommon and dangerous disorder of the heart. The two most frequent etiologic fungi discovered to be responsible for fungal endocarditis are Aspergillus and Candida species. It is difficult to make a diagnosis of fungal endocarditis; a comprehensive assessment must be carried out, and specific diagnostic requirements must be completed. One of the main causes of endocarditis that physicians deal with in the hospital is intravenous drug abuse, but we never hear about transdermal drug abuse causing endocarditis. Here we present an interesting case of a 33-year-old male patient that presents to the hospital with non-specific complaints, and he was found to have fungemia. It was found out that the patient was using a kitchen appliance to cause dermal abrasion on his skin to increase the absorption rate of his fentanyl patch. Patient also suffers from trypanophobia, so he declined any surgical intervention and wanted lifelong oral medication therapy.

Infective endocarditis caused by Chaetomium globosum.

Chaetomium globosum is a dematiaceous, filamentous fungus belonging to the large genus saprobic ascomycetes and is rarely involved in human infection. We present the case of a 25-year-old man undergoing tricuspid valve replacement due to recurrent prosthetic ring endocarditis. Initially, it was considered culture-negative endocarditis; however, the diagnosis of Chaetomium globosum could only be provided by DNA isolation of the mold isolate grown in culture and the valve tissue samples taken from the patient. This report describes the first documented tricuspid endocarditis caused by Chaetomium species and discusses the importance of molecular tools to enhance the diagnostic process in culture-negative endocarditis, especially for fastidious and nonculturable microorganisms.

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

Endocarditis, a life-threatening inflammation of the endocardium, is incited by bacteria, fungi, or other pathogenic microorganisms. Fungal endocarditis closely mirrors bacterial endocarditis in clinical signs and symptoms, leading to potential misdiagnoses. Here, we unveil the inaugural confirmed instance of native left-sided valve endocarditis attributed to Candida guilliermondii. Diagnosis was substantiated through valvular biopsies, blood and vegetative cultures. Treatment encompassed surgical excision of vegetations along with a six-week regimen of fluconazole administration (12 mg/kg/day), followed by 4 years of meticulous monitoring, resulting in sustained patient recovery.