Introduction:
Fungal endocarditis comprises less than 2% of infective endocarditis, with Aspergillus causing less than 28% of fungal endocarditis. Fungal endocarditis should be suspected in immunocompromised patients with persistent fevers, negative blood cultures, and vegetation on echocardiography. Invasive Aspergillus can affect any organ, but typically begins in the respiratory tract. Mortality rates climb to 90% with signs of hematogenous spread, such as cerebral abscesses.
Case Presentation:
Patient is a 53-year-old female with a past medical history of Sweet syndrome and chronic pancreatitis. Patient was admitted for persistent fevers and confusion. Patient was tachycardic but normotensive with a temperature of 102.5 F. Labs included significantly elevated serum LDH and Beta-D-Glucan. Blood cultures remained negative. Lumbar puncture cultures were negative; CSF cytology revealed pleocytosis with positive Aspergillus galactomannan serum antigen. Head MRI revealed multiple peripherally enhancing supratentorial lesions and intracranial abscesses (largest 8.4 mm) with ventriculitis of lateral ventricles, right greater than left. Transesophageal Echocardiogram (TEE) revealed mitral valve vegetation at A2 segment, no surrounding perivalvular abscess, minimal mitral regurgitation (MR).
Management:
Antibiotics were discontinued and patient was counseled on avoiding glucocorticoids. Patient was transferred to large tertiary center for Neurosurgery evaluation but was not candidate for biopsy/aspiration of the ring-enhancing lesions per Neurosurgery. Cardiothoracic Surgery was also consulted and patient was not a candidate for mitral valve replacement due to small size of vegetation without abscess and only mild MR. Voriconazole was continued and patient ultimately demonstrated a slow improvement in her strength and mental status over the next 6 months.
Discussion:
Mitral endocarditis from Aspergillus is rare but has a very high mortality rate. This case illustrates the importance of early recognition of systemic fungal infections in the setting of immunosuppression. Glucocorticoids and broad-spectrum antibiotics placed this patient at elevated risk for invasive Aspergillosis, which led to mitral endocarditis and subsequent cerebral abscesses from septic emboli.
Treatment of Infected Pseudoaneurysm of Femoral Artery after Vascular Closure Device Deployment: A Practical Solution
