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Isolated pulmonary valve infective endocarditis in a middle aged man caused by Candida albicans: a case report.

Devathi S, Curry B, Doshi S - BMC Infect. Dis. (2014)

Bottom Line: He was initially diagnosed with pneumonia but did not improve with empiric antibacterial therapy.Follow up echocardiography after completion of therapy did not show any vegetations and the patient clinically improved.While surgery should be considered in all cases of Candida endocarditis, cure may be achieved with antifungal therapy alone.

View Article: PubMed Central - PubMed

ABSTRACT

Background: Pulmonary valve endocarditis without the involvement of other valves represents 1.5-2% of all cases of infective endocarditis. Isolated pulmonary valve endocarditis caused by Candida is extremely rare with only one reported case in the literature and none reported in the United States. Guidelines for management of Candida endocarditis recommend a combination of medical and surgical therapy.

Case presentation: A 61-year-old homeless male presented with fever, cough and shortness of breath. He was urgently intubated for hypoxia. He was initially diagnosed with pneumonia but did not improve with empiric antibacterial therapy. Candida species were isolated from bronchoalveolar lavage fluid and the patient eventually developed persistent C. albicans bloodstream infection. On further workup he was found to have infective endocarditis with a large vegetation across the pulmonary valve. No other valves were involved. He was treated with intravenous antifungal therapy for eight weeks. Valvular surgery was not performed. Follow up echocardiography after completion of therapy did not show any vegetations and the patient clinically improved.

Conclusion: This is the second reported case of isolated pulmonary valve endocarditis caused by Candida and the first to be successfully managed with antifungal therapy alone. Pulmonary valve endocarditis should be considered in cases of pneumonia with Candida and persistent fungemia. While surgery should be considered in all cases of Candida endocarditis, cure may be achieved with antifungal therapy alone.

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Transesophageal echocardiogram. A. Pulmonary valve vegetation B. No vegetation after four weeks of Amphotericin B.
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Fig2: Transesophageal echocardiogram. A. Pulmonary valve vegetation B. No vegetation after four weeks of Amphotericin B.

Mentions: Bronchoscopy performed on hospital day three showed black secretions from the right lower lobe. He was started on Micafungin after bronchoalveolar lavage cultures grew Candida albicans and Candida glabrata. Trans-bronchial biopsy was not performed due to friable mucosa. Trans-thoracic echocardiogram on hospital day five revealed no valvular abnormalities or vegetations. Because of persistent fever and hypoxia, a second bronchoscopy was performed on hospital day eight, which still showed black secretions; bronchoalveolar lavage cultures grew Candida glabrata. Two sets of blood cultures collected on hospital day twelve grew Candida albicans. A central venous catheter that had been placed on admission was removed; culture of the catheter tip showed no growth. Amphotericin B lipid complex was initially added to Micafungin. After his creatinine rose from 0.9 to 4.5 mg/dL, this was switched to Liposomal Amphotericin B; his creatinine normalized to 1.1 mg/dL by hospital day thirty. Additionally, his WBC count rose to 4.9 × 103/μL with 68% neutrophils calculated on an automated differential with no interventions other than treating his underlying sepsis. The patient defervesced three days after amphotericin B was added and Micafungin was discontinued. However, repeat blood cultures on hospital day fourteen again grew Candida albicans. A trans-esophageal echocardiogram (TEE) performed on hospital day sixteen showed a 1.5 cm mobile mass on the pulmonary valve extending from the right ventricular outflow tract across the pulmonary valve into the pulmonary artery (Figure 2A).Figure 2


Isolated pulmonary valve infective endocarditis in a middle aged man caused by Candida albicans: a case report.

Devathi S, Curry B, Doshi S - BMC Infect. Dis. (2014)

Transesophageal echocardiogram. A. Pulmonary valve vegetation B. No vegetation after four weeks of Amphotericin B.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4221716&req=5

Fig2: Transesophageal echocardiogram. A. Pulmonary valve vegetation B. No vegetation after four weeks of Amphotericin B.
Mentions: Bronchoscopy performed on hospital day three showed black secretions from the right lower lobe. He was started on Micafungin after bronchoalveolar lavage cultures grew Candida albicans and Candida glabrata. Trans-bronchial biopsy was not performed due to friable mucosa. Trans-thoracic echocardiogram on hospital day five revealed no valvular abnormalities or vegetations. Because of persistent fever and hypoxia, a second bronchoscopy was performed on hospital day eight, which still showed black secretions; bronchoalveolar lavage cultures grew Candida glabrata. Two sets of blood cultures collected on hospital day twelve grew Candida albicans. A central venous catheter that had been placed on admission was removed; culture of the catheter tip showed no growth. Amphotericin B lipid complex was initially added to Micafungin. After his creatinine rose from 0.9 to 4.5 mg/dL, this was switched to Liposomal Amphotericin B; his creatinine normalized to 1.1 mg/dL by hospital day thirty. Additionally, his WBC count rose to 4.9 × 103/μL with 68% neutrophils calculated on an automated differential with no interventions other than treating his underlying sepsis. The patient defervesced three days after amphotericin B was added and Micafungin was discontinued. However, repeat blood cultures on hospital day fourteen again grew Candida albicans. A trans-esophageal echocardiogram (TEE) performed on hospital day sixteen showed a 1.5 cm mobile mass on the pulmonary valve extending from the right ventricular outflow tract across the pulmonary valve into the pulmonary artery (Figure 2A).Figure 2

Bottom Line: He was initially diagnosed with pneumonia but did not improve with empiric antibacterial therapy.Follow up echocardiography after completion of therapy did not show any vegetations and the patient clinically improved.While surgery should be considered in all cases of Candida endocarditis, cure may be achieved with antifungal therapy alone.

View Article: PubMed Central - PubMed

ABSTRACT

Background: Pulmonary valve endocarditis without the involvement of other valves represents 1.5-2% of all cases of infective endocarditis. Isolated pulmonary valve endocarditis caused by Candida is extremely rare with only one reported case in the literature and none reported in the United States. Guidelines for management of Candida endocarditis recommend a combination of medical and surgical therapy.

Case presentation: A 61-year-old homeless male presented with fever, cough and shortness of breath. He was urgently intubated for hypoxia. He was initially diagnosed with pneumonia but did not improve with empiric antibacterial therapy. Candida species were isolated from bronchoalveolar lavage fluid and the patient eventually developed persistent C. albicans bloodstream infection. On further workup he was found to have infective endocarditis with a large vegetation across the pulmonary valve. No other valves were involved. He was treated with intravenous antifungal therapy for eight weeks. Valvular surgery was not performed. Follow up echocardiography after completion of therapy did not show any vegetations and the patient clinically improved.

Conclusion: This is the second reported case of isolated pulmonary valve endocarditis caused by Candida and the first to be successfully managed with antifungal therapy alone. Pulmonary valve endocarditis should be considered in cases of pneumonia with Candida and persistent fungemia. While surgery should be considered in all cases of Candida endocarditis, cure may be achieved with antifungal therapy alone.

Show MeSH
Related in: MedlinePlus