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CASE REPORT
Year : 2022  |  Volume : 10  |  Issue : 3  |  Page : 165-167

Fungal endocarditis: A rare presentation


1 Department of Anatomical Pathology and Cytology, Hyderabad, Telangana, India
2 Deccan College of Medical Sciences,Hyderabad, Telangana, India
3 Department of Cardiology, Internal Medicine, Hyderabad, Telangana, India

Date of Submission30-Jun-2022
Date of Decision08-Sep-2022
Date of Acceptance14-Sep-2022
Date of Web Publication14-Dec-2022

Correspondence Address:
Sistla Radha
Department of Anatomical Pathology and Cytology, Hyderabad, Telangana,
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartindia.heartindia_29_22

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  Abstract 


Endocarditis is inflammation of the innermost lining of the heart including the valves. It can be of infective or noninfective etiology. It is a relatively rare disease with high morbidity and mortality. There are a very few cases reported from India. Infective endocarditis due to fungal organisms accounts for 2%–4% of endocarditis. We report a case of Aspergillus endocarditis in a patient with chronic rheumatic heart disease, which was incidentally diagnosed during surgery. The patient was treated with mitral valve replacement and antifungal agents. One year after surgery, the patient has a good prosthetic valve function with no evidence of vegetations.

Keywords: Aspergillus, endocarditis, immunocompetent patient


How to cite this article:
Radha S, Afroz T, Amaan MU, Swamy M. Fungal endocarditis: A rare presentation. Heart India 2022;10:165-7

How to cite this URL:
Radha S, Afroz T, Amaan MU, Swamy M. Fungal endocarditis: A rare presentation. Heart India [serial online] 2022 [cited 2023 Feb 2];10:165-7. Available from: https://www.heartindia.net/text.asp?2022/10/3/165/363537




  Introduction Top


Fungal endocarditis is an infrequent, debilitating disease. It involves native valves, prosthetic valves, or endocardial surfaces. The risk factors for fungal endocarditis are the presence of prosthetic valves, long-standing central lines, immunosuppressed states, prolonged use of steroids, and prolonged antibiotic usage.

On echocardiography, fungal vegetations are large and usually valvular in location. Our case is unique in that there were no valvular vegetations and the endocardium around the valve was the involved site. There were no immunocompromising conditions. The incidence of fungal endocarditis in the literature was 0.25%–2.5% of infective endocarditis.


  Case Report Top


A 51-year-old female presented with shortness of breath and chest pain for the past 1 month. She is a known case of rheumatic heart disease with mitral regurgitation. She had moderate pulmonary artery hypertension and sick sinus syndrome. She is not a known diabetic or hypertensive. She was a moderately built female; her blood pressure was 140/80, and her heart rate was 90/min. Routine hematological and biochemical investigations were within the normal limits. She was HIV nonreactive, and her hepatitis markers were negative. Preoperative screening for COVID-19 was negative. There was no history of COVID-19-related infection. Echocardiogram revealed severe mitral regurgitation, dilated left atrium, mild tricuspid regurgitation, and moderate pulmonary arterial hypertension. She had a fair ventricular function and a clot along the left atrial wall. There were no vegetation on the valves. Her coronary angiogram was normal. Intraoperatively, the mitral valve was bicuspid with thickened leaflets and fused commissures and felt firm. There was no clot or vegetations. Endocardium appeared granular. A biopsy was taken from the endocardium, and the mitral valve was replaced by a prosthetic valve. Her recovery was uneventful. Postoperative echocardiogram showed normal prosthetic valve, and no valvular leak was noted. She was put on fluconazole 400 mg bd. She is on a regular follow-up with no evidence of endocarditis. Histological examination revealed branching septate hyphae with a granulomatous reaction around there were small foci of necrosis. This was confirmed on the Gomori methenamine stain [Figure 1]a and [Figure 1]b.
Figure 1: (a) Granulomas composed of epithelioid cells and giant cells (H and E ×200). (b) Fungal stains with Gomori methenamine stain revealed septate hyphae with branching, morphologically consistent with Aspergillosis (×400)

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  Discussion Top


Fungal endocarditis is an uncommon disease. The incidence is on the rise with increase in invasive procedures. Fungal endocarditis accounts for 0.1% of prosthetic cardiac valves.[1] Koelle and Pastor, in 1956, reported the first case of fungal endocarditis. Fungal endocarditis can present as native valve disease, prosthetic valve involvement, endocardial surface involvement, or cardiac device-related endocarditis. The incidence of fungal endocarditis involving the endocardial surface is reported as 4.44% in a large literature review analysis of 270 cases of fungal endocarditis.[2] Two-thirds of cases of fungal endocarditis were caused by Candida species and one-third by Aspergillus species. The incidence of fungal endocarditis is 2%–4%, and in India, reported incidence is 1.1%–2.7%. Candida species, in particular, Candida albicans, are the most common causative organisms of fungal endocarditis. Aspergillus sp. including Aspergillus flavus, Aspergillus fumigatus, and Aspergillus niger are also common organisms causing fungal endocarditis. Aspergillus species are found to be more prevalent in prosthetic valve endocarditis.[3] This case is presented due to its rare clinical features. Mycotic endocarditis is reported with intravenous drug abuse, anatomical cardiac abnormality, open-heart surgery, immunosuppressive drugs and malignancy, prolonged use of broad-spectrum antibiotics, prolonged intravenous catheters, and rheumatic heart disease. Early diagnosis is very crucial for better outcomes in Aspergillus endocarditis. In general, diagnosis can be made by echocardiography and multiple blood cultures and/or biopsies;[4] the diagnosis of Aspergillus endocarditis can be challenging as the blood culture yield is very poor, despite the presence of vegetation on echocardiography. Only 4%–30% of Aspergillus endocarditis cases show positive blood cultures.[5]

Clinical manifestations of fungal endocarditis are not specific. A high index of clinical suspicion is required in susceptible patients to make an early diagnosis and promptly treat the patients to improve the outcome. Characteristic fungal endocarditis presents as large vegetations with a tendency to grow on the valves and embolism. Our case, in contrast, had fine granular endocardium in the heart chamber close to the valve, and there were no vegetations on the valve clinically or histologically. Fungal endocarditis in rheumatic valves is known, but the involvement of the endocardium around the valve and not the valve per se is a little peculiar. Aspergillus infection is difficult to diagnose. Galactomannan antigen assay is a useful adjunct in invasive aspergillosis. It is not well studied in endocarditis. Hence, the gold standard for diagnosis is histopathological examination and tissue cultures. The case under discussion is peculiar in the sense that the valve that is involved by rheumatic disease is not involved by fungal infection, but the surrounding endocardium revealed invasive fungus. Currently, new nonculture methods have been developed to detect the presence of fungus in the blood. These include galactomannan antigen and antibody tests, 1, 3-β-D-glucan test, polymerase chain reaction (PCR), real-time PCR targets, and next-generation sequencing.[6]


  Conclusions Top


Fungal endocarditis is rare, with high mortality and morbidity. A high index of suspicion is required for early diagnosis and prompt treatment. Any unhealthy looking tissue during surgery should be subjected to histopathology, which clinched the diagnosis in this case, and still is the gold standard for diagnosing fungal endocarditis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical approval

This is not a research study for ethical approval as it is a case study. However it has been approved for publication by the institutes ethical board.

Authors' contributions

Sistla Radha- Manuscript Preparation and Final Manuscript Editing Tameem Afroz- Manuscript Editing, Literature Search and Final Editing Mohammed Umar Amaan- Manuscript Editing, Literature Search Mallindra Swamy- Manuscript Editing.



 
  References Top

1.
Sun XL, Zhang J, Wang GG, Zhuang XF, Yang YM, Zhu J, et al. Comparison of characteristics and short-term outcome from fungal infective endocarditis in prosthetic valve endocarditis versus native valve endocarditis. Am J Cardiol 2013;112:111-6.  Back to cited text no. 1
    
2.
Ellis ME, Al-Abdely H, Sandridge A, Greer W, Ventura W. Fungal endocarditis: Evidence in the world literature, 1965-1995. Clin Infect Dis 2001;32:50-62.  Back to cited text no. 2
    
3.
Millar BC, Jugo J, Moore JE. Fungal endocarditis in neonates and children. Pediatr Cardiol 2005;26:517-36.  Back to cited text no. 3
    
4.
Yuan SM. Fungal endocarditis. Braz J Cardiovasc Surg 2016;31:252-5.  Back to cited text no. 4
    
5.
Pasha AK, Lee JZ, Low SW, Desai H, Lee KS, Al Mohajer M. Fungal endocarditis: Update on diagnosis and management. Am J Med 2016;129:1037-43.  Back to cited text no. 5
    
6.
Ammannaya GK, Sripad N. Fungal endocarditis: What do we know in 2019? Kardiol Pol 2019;77:670-3.  Back to cited text no. 6
    


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Discussion
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