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Native valve infective endocarditis usually affects the mitral or aortic valve and the incidence of systemic embolization is about 20%. Fungal endocarditis, which accounts for 1% of cases, has special features.
A man aged 72 was admitted after becoming increasingly short of breath in the past week, much worse over the past two days. On the day of admission he had had a cough and some haemoptysis. Eleven months previously he had had an anterior resection for rectal carcinoma and had subsequently required readmission with signs of peritonitis and renal failure. At laparotomy the anastomosis was found to have broken down with faecal peritonitis and a Hartmann's procedure was performed. He had a protracted and stormy course in the intensive therapy unit with multiple episodes of sepsis including meticillin-resistant Staphylococcus aureus, pseudomonas and lastly Candida albicans in blood cultures. He eventually recovered, but four weeks before the current admission an isotope ventilation and perfusion scan, requested by his general practitioner, had shown a high probability of pulmonary emboli (Figure 1) and he had been started on anticoagulants.
On examination he was dyspnoeic with slight bilateral pedal oedema and a raised jugular venous pressure. Oxygen saturation was 69% on air and the provisional diagnosis was recurrent pulmonary embolism; this became less likely when the international normalized ratio was reported as 5.3. He remained very short of breath, and an echocardiogram three days after admission showed a large vegetation on the tricuspid valve, 2.2 cm in diameter (Figure 2). There was mild dilatation of the right atrium and ventricle and pulmonary artery pressure was considerably above normal (about 60 mmHg). A CT pulmonary angiogram then revealed large filling defects in the artery to the left lower lobe and also filling defects in both upper lobe arteries (Figure 3). Subsequently, blood cultures yielded C. albicans identical to the strain isolated during the patient's previous stay in the intensive care unit. Flucytosine and amphotericin were prescribed.
At operation the chest was opened through a median sternotomy and pulmonary artery pressures were found to be about two-thirds of systemic. Full cardiopulmonary bypass was established with ascending aortic return and bicaval venous drainage. The anterior and septal leaflets of the tricuspid valve proved to be completely covered with fungal growth. The valve was partly excised and reconstructed. Large amounts of embolic fungal material were removed by means of a standard embolectomy catheter from the left lower and right upper lobe arteries and a smaller amount from the left upper pulmonary artery. Subsequent cultures from the tricuspid valve confirmed the presence of C. albicans. The antifungal regimen was continued and the patient was discharged six weeks after admission.
In the typical case of infective endocarditis the offending organism is bacterial and affects valves on the left side (mitral or aortic) previously abnormal because of rheumatic disease or congenital defects.1 Fungal endocarditis, by contrast, is usually right-sided and causes larger vegetations with a greater likelihood of embolization. The ultrasound features of candida endocarditis have been described by Donal and co-workers.2 Reviewing 270 published cases of fungal endocarditis (C. albicans 24%, non-albicans Candida spp. 24%, Aspergillus spp. 24%) Ellis et al.3 found that the major risk factors were non-cardiac surgery, vascular lines, immunocompromise and injection drug abuse. The second two may well have contributed in our patient. The aim of surgical treatment is to remove vegetations while conserving the valve, and to extract pulmonary emboli.4-6