We will present a case report of a previously healthy twenty-three year old Caucasian female patient, from a higher social-culture level, living in Belgrade suburbs. She had a negative history data to preexisting diseases, drug use or any underlining conditions.
First symptom-fever, presented four months before hospital admittance, was treated with third generation cephalosporin (ceftriaxone 2,0 gr daily i.v.) and resolved within 5 days. During the next month she was febrile without other symptoms. During that time the patient was observed in a local hospital, until her condition deteriorated - with anemia, leucopenia and petechial skin rash, and she was transferred to the Institute for Infectious and Tropical Diseases, Belgrade, Clinical Centre of Serbia. Clinical findings on admission included discreet petechial skin rash, moderate hepatosplenomegaly, whereas other systems were unaffected, including normal heart sounds. Laboratory tests showed moderate elevation of erythrocyte sedimentation rate, intermediary anemia and leucopenia, with elevated C-reactive protein. (Table ) Candida parapsilosis- sensitive to all systemic antifungal drugs was isolated in multiple blood cultures. The initial treatment included IV fluconazole 200 mg/12 h. During the third day of therapy, a newly developed systolic murmur was noted, presenting an indication for echocardiography. The patient was afebrile starting from that moment.
Laboratory results during course of illness, and follow-up
Echocardiography revealed 15
14 mm vegetations on the right aortic vellum. (Figure ) As Candida endocarditis usually appears in immunosuppressive patients as well as in patients with prosthetic valves, extensive clinical investigation was performed, to uncover any possible cause of immunosuppression. During a four-week period, all possible infectious agents were tested, including HIV, HBV, HCV, EBV, Leischmania
and tuberculosis. Normal absolute count and ratio of CD4, CD2, CD3 and CD8 lymphocytes was noted, as well as normal concentration of immunoglobulines and sufficient immunological functions. There were no markers of autoimmune diseases which could affect the immune system. Hematological investigation was performed, as well as abdominal and chest CT, so the possible presence of solid tumors was excluded. A "10-panel urine screen" drug test was negative. During investigation, the patient was treated with fluconazole (200 mg/12 h, i.v.). Control echocardiography showed progressive enlargement of vegetations, spreading to the other vellum, so the treatment was continued with liposomal amphotericin B intravenously, 50 mg daily. Since the transoesophageal echocardiography showed that after two weeks of new treatment there were two additional vegetations affecting vellums (17
6 mm and 12
3 mm), it was necessary to replace the affected heart valve. Control blood cultures, repeated daily from the fifth day of hospitalization (patient was afebrile), were sterile. Preoperatively, patient was treated with fluconazole for 38 days, and liposomal amphotericin B for 15 days. The affected valve (Figure ) was successfully replaced, and the same strain of Candida parapsilosis
was isolated from intraoperative material of the valve.
Transthoracal echocardiografy in longitudinal and apical 4 chamber view vegetations on the aortic valves.
Intraoperaive vegetation findings - aortic valve.
Further conservative antifungal therapy was administered after operation, until laboratory findings were normalized, five months later. During this period the patient was treated with liposomal amphotericin B for 36 days, IV in the daily dose of 50 mg. For the rest of the period she was treated with fluconazole IV 200 mg in the dose intervals of 12 hours (approximately four months). During the whole period, no side-effects were observed.
During the 3 year follow-up, there were no other pathological developments, and the patient has been physically active and working.