Approximately 25% of cases of fungal endocarditis are caused by an Aspergillus species. The increased incidence of invasive aspergillosis (IA) has not been accompanied by a rise in Aspergillus endocarditis (AE). Valvular abnormalities are found in about 2 / 3 cases. Cases have been described following nonvalvular surgery, including coronary artery bypass grafting and pacemaker insertion. Predisposing factors are similar to those of IA eg immunocompromise, malignancy, neutropenia, prolonged broad spectrum antibiotics and injecting drug use. Diagnosis of AE is difficult and usually delayed frequently at surgery, and at post-mortem in about 1 / 3 cases. Blood culture positivity rates are low. The most common clinical features are 1) fever; 2) a new or changing murmur; 3) emboli, particularly femoral or cerebral; 4) focal or generalized cerebral lesions; 5) cardiac failure. Clubbing, Osler’s nodes and splenomegaly are uncommon. Bulky vegetations are often found at echocardiography. Successful treatment usually requires a combined medical and surgical approach although case reports without surgery have been described. High dose liposomal Amphotericin B is the drug of choice. Surgery almost invariably involves valve replacement although vegectomy has been described. The mortality rate is approximately 90%, reflecting host factors, diagnostic difficulties and the inherent pathogenicity of the fungus. Recurrence rates are unknown for a condition with such a high mortality rate. Long term voriconazole following acute AE seems prudent although there are no studies on this issue. Future directions of AE research should involve predisposing and risk factors eg mannose binding lectin deficiency, and the diagnostic usefulness of serological and molecular testing. Further studies on the roles of more recently developed antifungal agents, including voriconazole and echinocandins are needed. AE is a condition where drug combinations may be superior to monotherapy.
Full conference title:
4th Advances Against Aspergillosis
- AAA 4th (2010)