ABSTRACT
Relatar o caso de um paciente com múltiplas trocas valvares aórticas, imunocompetente, com diagnóstico de endocardite fúngica por T. asahii. Relato do caso: Homem, 63 anos, com história de febre reumática e quatro trocas da valva aórtica que evoluiu com sintomas de insuficiência cardíaca aguda e febre. Não foi encontrada nenhuma evidência de imunossupressão. Os exames laboratoriais demonstraram anemia e plaquetopenia leves, com leucograma normal e elevação de lactato desidrogenase e proteína C reativa. O ecocardiograma revelou insuficiência aórtica importante e múltiplas vegetações na valva aórtica. T. asahii foi isolado em duas hemoculturas, sendo iniciada a administração de anfotericina B. O paciente necessitou de cirurgia de emergência para nova troca valvar por deterioração clínica. Em decorrência de complicações intraoperatórias, evoluiu para óbito. Discussão: O diagnóstico e o tratamento da endocardite por T. asahii não estão bem estabelecidos na literatura. Os antifúngicos disponíveis atualmente são triazóis e anfotericina B, com evidências que sugerem superioridade dos triazóis, mas a cirurgia é necessária por ineficácia desses fármacos isoladamente. Conclusões: Faltam dados sobre o tratamento medicamentoso mais eficaz e seguro para a endocardite por T. asahii. Neste caso, as trocas valvares prévias agregaram dificuldade técnica ao novo procedimento, que resultou em evolução desfavorável. Não há dados de literatura sobre o momento ideal para troca valvar em pacientes com múltiplas trocas valvares prévias
To present the case report of an immunocompetent patient with multiple aortic valve replacements, diagnosed with fungal endocarditis due to T. asahii. Case report: A 63-year-old male patient with a history of rheumatic fever and four aortic valve replacements, who progressed with symptoms of acute heart failure and fever. No evidence of immunosuppression was found. Laboratory tests detected mild anemia and thrombocytopenia, with normal leukogram and elevated lactate dehydrogenase and C-reactive protein levels. The echocardiogram revealed severe aortic insufficiency and multiple aortic valve vegetations. T. asahii was isolated in two blood cultures, and administration of amphotericin B was initiated. The patient required emergency surgery for a further valve replacement due to clinical deterioration. The patient later died as a result of intraoperative complications. Discussion: Diagnosis and treatment of T. asahii endocarditis are not well established in the literature. The currently available antifungals are triazoles and amphotericin B, with evidence suggesting superiority of the former, but surgery is required because of the ineffectiveness of these drugs alone. Conclusions: There is insufficient data on the safest and most effective pharmaceutical treatment for T. asahii endocarditis. In this case, the previous valve replacements added technical difficulty to the new procedure, which resulted in an unfavorable outcome. There is no data in the literature on the optimal timing for valve replacement in patients with multiple prior replacements
Subject(s)
Humans , Male , Middle Aged , Aortic Valve , Trichosporon , Endocarditis/mortality , Immunocompetence , Prostheses and Implants , Echocardiography/methods , Risk Factors , Electrocardiography/methods , Fungi , Heart Failure/complicationsABSTRACT
PURPOSE: Demonstrate that the blockade of angiotensin II AT-1 receptors, through the systemic administration of olmesartan, can reduce the MCP-1 expression and the resulting macrophage accumulation in the choroid and sclera of hypercholesterolemic rabbits. METHODS: Thirty-two New Zealand rabbits were divided into 3 groups: group I (GI) was fed a standard rabbit diet; group II (GII) was fed a hypercholesterolemic diet; and group III (GIII) was fed a hypercholesterolemic diet plus olmesartan. Serum levels of total cholesterol, triglyceride, HDL cholesterol, and blood glucose were determined in fasting rabbits at the beginning of the experiment and on the day of euthanasia. The choroid and sclera were submitted to morphometric analysis as well as immunohistochemical analysis with MCP-1 and RAM-11 (macrophage marker) antibodies. RESULTS: No abnormality was detected in GI. Group II and III had significant increases in choroid-sclera complex thicknesses when compared with group I (P<0.001). GII showed a significant increase in immunoreactivity for MCP-1 in relation to GI (P=0.001) and GIII (P=0.004). GII showed a significant increase in immunoreactivity for RAM-11 of the choroid-sclera complex in relation to GI (P<0.001) and GIII (P=0.034). A significant increase in immunoreactivity for RAM-11 was observed in GIII in relation to GI (P=0.008). CONCLUSION: Olmesartan reduced the MCP-1 expression and the resultant macrophage accumulation in the choroid-sclera complex of hypercholesterolemic rabbits.
