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      Aspergillus endocarditis diagnosed by fungemia plus serum antigen testing

      case-report

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          Abstract

          Fungal endocarditis remains an uncommon clinical diagnosis, though is likely to become more frequent due to the global increase in transplantations and cardiac valvular surgery. A case of prosthetic valve endocarditis due to Aspergillus fumigatus is described that was diagnosed with serologic fungal markers and confirmed with positive blood cultures, an uncommon finding.

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          Combination antifungal therapy for invasive aspergillosis: a randomized trial.

          Oliver Cornely, J Maertens, Monica Slavin … (2015)
          Invasive aspergillosis (IA) is associated with poor outcomes in patients with hematologic malignancies (HMs) and hematopoietic cell transplantation (HCT). Small studies suggest a role for combination antifungal therapy. To assess the safety and efficacy of voriconazole and anidulafungin compared with voriconazole monotherapy for treatment of IA. Randomized, double-blind, placebo-controlled multicenter trial. (ClinicalTrials.gov: NCT00531479). 93 international sites. 454 patients with HM or HCT and suspected or documented IA were randomly assigned to treatment with voriconazole and anidulafungin or placebo. Primary analysis was done in the modified intention-to-treat population of 277 patients in whom IA was confirmed. The primary outcome was 6-week mortality; secondary outcomes included 12-week mortality, mortality in major subgroups, and safety measures. Mortality rates at 6 weeks were 19.3% (26 of 135) for combination therapy and 27.5% (39 of 142) for monotherapy (difference, -8.2 percentage points [95% CI, -19.0 to 1.5]; P  = 0.087). Secondary mortality outcomes favored combination therapy. Multivariable regression analysis suggested that maximum galactomannan value, Karnofsky score, and baseline platelet count had prognostic significance. Most patients (218 of 277 [78.7%]) had IA diagnosis established by radiographic findings and maximum galactomannan positivity. In a post hoc analysis of this dominant subgroup, 6-week mortality was lower in combination therapy than monotherapy (15.7% [17 of 108] vs. 27.3% [30 of 110]; difference, -11.5 percentage points [CI, -22.7 to -0.4]; P = 0.037). Safety measures, including hepatotoxicity, were not different. Mortality at 6 weeks was higher than expected, and the difference in mortality was lower than expected, which reduced power to detect a treatment effect. Enrollment was restricted to patients with HM or HCT, which limited generalizability. Compared with voriconazole monotherapy, combination therapy with anidulafungin led to higher survival in subgroups of patients with IA. Limitations in power preclude definitive conclusions about superiority. Pfizer.
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            Fungal endocarditis: evidence in the world literature, 1965-1995.

            M. Ellis, H. Al-Abdely, A. Sandridge … (2001)
            We analyzed 270 cases of fungal endocarditis (FE) that occurred over 30 years. Vascular lines, non-cardiac surgery, immunocompromise and injection drug abuse are increasing risk factors. Delayed or mistaken diagnosis (82% of patients), long duration of symptoms before hospitalization (mean +/- standard deviation, 32+/-39 days) and extracardiac manifestations were characteristic. From 1988 onwards, 72% of patients were diagnosed preoperatively, compared with 43% before 1988 (P=.0001). The fungi most commonly isolated were Candida albicans (24% of patients), non-albicans species of Candida (24%), Apergillus species (24%), and Histoplasma species (6%); recently-emerged fungi accounted for 25% of cases. The mortality rate was 72%. Survival rates were better among patients who received combined surgical-antifungal treatment, were infected with Candida, and had univalvular involvement. Improvement in the survival rate (from or =4 years while on prophylactic antifungal therapy.
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              Fungal endocarditis, 1995-2000.

              Ligia C. Pierrotti, Larry M Baddour (2002)
              One hundred fifty-two cases of fungal endocarditis (FE) were identified in the English-language literature between January 1, 1995, and June 30, 2000. Although the median age of patients (44 years) was relatively young, injection drug use was identified as a risk factor in only 4.1% of cases. Other factors, including underlying cardiac abnormalities (47.3%), prosthetic valves (44.6%), and central venous catheters (30.4%), were more commonly identified as predisposing conditions and reflect the changing epidemiology of the syndrome. Unfortunately, mortality remains unacceptably high, particularly for patients with Aspergillus-related FE. Novel therapies are needed to improve patient outcomes.
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                Author and article information

                Contributors
                Timothy J. Hatlen
                Journal
                Journal ID (nlm-ta): Med Mycol Case Rep
                Journal ID (iso-abbrev): Med Mycol Case Rep
                Title: Medical Mycology Case Reports
                Publisher: Elsevier
                ISSN (Electronic): 2211-7539
                Publication date PMC-release: 25 October 2018
                Publication date Collection: March 2019
                Publication date (Electronic): 25 October 2018
                Volume: 23
                Pages: 1-3
                Affiliations
                [a ]Division of Infectious Diseases, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, CA 90509, USA
                [b ]Division of Cardiology, Harbor-UCLA Medical Center, Torrance, CA 90509, USA
                [c ]Department of Pathology, Harbor-UCLA Medical Center, Torrance, CA 90509, USA
                [d ]Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA 90095, USA
                Author notes
                [* ]Correspondence to: Harbor-UCLA Medical Center, 1000 W Carson, Box 466, Torrance, CA 90509, USA. thatlen@ 123456dhs.lacounty.gov
                Article
                Publisher ID: S2211-7539(18)30116-7
                DOI: 10.1016/j.mmcr.2018.10.004
                PMC ID: 6216080
                PubMed ID: 30416954
                SO-VID: 02cb25ff-5ff2-4687-a4d0-81af6b0defd1
                License:

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

                History
                Date received : 22 September 2018
                Date accepted : 22 October 2018
                Categories
                Subject: Case Report

                Keywords: fungal endocarditis,aspergillus fumigatus,fungemia
                Data availability:
                Keywords: fungal endocarditis, aspergillus fumigatus, fungemia

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