Fungal endocarditis, a rare manifestation of invasive fungal infection in an immunocompromised patient

B. Hendriks2, A.L. Van de Velde1, E. Steel1, T. Van den Wyngaert4, B. Ogunjimi4, T. Panis4, M.M. Ieven3 and A.P.

Author address: 

1Antwerp University Hospital, Hematology, 2Antwerp University Hospital, Tropical Medicine, 3Antwerp University Hospital, Microbiology, Edegem and 4Antwerp University, Medicine, Antwerp, Belgium

Abstract: 

Background: Fungi are an uncommon cause (16%) of infective endocarditis with aspergillus species being demonstrated in 25% of fungal endocarditis (FE). In the absence of positive blood cultures or accessible peripheral emboli for biopsy, consecutive aspergillus antigen detection may represent an additional, non invasive and rapid diagnostic tool orienting the clinician to a fungal etiology, thereby initiating antifungal therapy in an earlier stage, prior to a thoracotomic biopsy of the vegetation. Case report: We present a 63-year-old man with chronic obstructive pulmonary disease (COPD) and low-grade small cell B-cell non- Hodgkin lymphoma, on low dose corticosteroid maintenance therapy. He was admitted because of subfebrilitas, progressive dyspnea, weight loss and a productive cough. Routine blood analysis showed normal white blood cell count with neutrophil predominance and slightly elevated C reactive protein. There were no pulmonary infiltrates on chest X ray. CT scan revealed non specific interstitial infiltrates.Reentry tachycardia was succesfully treated farmacologically. A tentative diagnosis of infectious exacerbation of COPD was made. However, transthoracal echocardiography showed a right atrial tumor. The vegetation (2 x 3 cm) at the junction of the vena cava inferior and the right atrium was confirmed by transesophageal echocardiography (TEE) and magnetic resonance immaging. Repeated blood cultures remained negative. Broncho-alveolar lavage was not performed because of respiratory distress. Galactomannan testing was repeatedly strongly positive (> 3 ng/ml). Despite a nonspecific clinical presentation and CT scan findings, absence of culture proven or histopathologic evidence of IA, the diagnosis of a fungal endocardiditis was made. Tapering of corticosteroids and empirical initiation of antifungal therapy with voriconazole resulted in a gradual improvement of the patients overall health, with a rapid decrease in serum galactomannan levels. After two months the vegetation was no longer visible by TEE. Although the literature supports an improved outcome by a combined medical and surgical approach, our patient was deemed ineligible for surgery for medical reasons. Fungal endocarditis recurs in 30% of cases. Therefore, life-long suppressive antifungal therapy has been advocated. Conclusion: The addition of the recently validated Galactomannan ELISA test to the existing microbiological criteria in the definition of invasive aspergillosis, next to the clinical and host criteria, may result in an earlier diagnosis of this potentially fatal complication and consequently to an improved outcome of the underlying hematological disease. Galactomannan testing in culture negative endocarditis may focus the attention to a fungal etiology in an earlier stage.
2005

abstract No: 

P125

Full conference title: 

2nd Trends in Medical Mycology
    • TIMM 2nd (2010)