Tricuspid valve Candida endocarditis cured by valve-sparing debridement

More than Garden Variety: Massive Vegetations from Infective Endocarditis

Infective endocarditis classically involves non-sterile vegetations on valvular surfaces in the heart. Feared complications include embolization and acute heart failure. Surgical intervention achieves source control and alleviates valvular regurgitation in complicated cases. Vegetations >1 cm are often intervened upon, making massive vegetations uncommon in modern practice. We report the case of a 39-year-old female with history of intravenous drug abuse who presented with a serpiginous vegetation on the native tricuspid valve and methicillin-resistant Staphylococcus aureus bacteremia. The vegetation grew to 5.6 cm by hospital day two, and she successfully underwent a tricuspid valvectomy. Six weeks of intravenous vancomycin therapy were completed without adverse events. To better characterize other dramatic presentations of infective endocarditis, we performed a systematic literature review and summarized all case reports involving ≥4 cm vegetations.

Candida tropicalis endocarditis successfully treated with AngioVac and micafungin followed by long-term isavuconazole suppression

We provide a review of current literature of native valve Candida tropicalis endocarditis.

A 41-year old man presented with C. tropicalis candidemia complicated by superior vena cava mass and right main pulmonary artery thrombus. The patient achieved clinical and microbiologic cure with AngioVac of the mass and echinocandin for six weeks. Long-term suppression was challenging given the C. tropicalis strain was resistant to fluconazole, voriconazole and posaconazole. Additional susceptibilities were obtained and he remained relapse-free at 12 months with isavuconazole.

A meta-analysis of medical versus surgical therapy for Candida endocarditis

OBJECTIVES

The optimal management of Candida infective endocarditis (IE) is unknown.

METHODS

We reviewed all 879 cases of Candida IE reported from 1966-2002 in the peer-reviewed literature to better understand the role of medical and surgical therapies. This review included 163 patients from 105 reports that met our inclusion criteria: 31 cases treated with antifungal monotherapy, 25 cases treated with medical antifungal combination therapy, and 107 cases treated with adjunctive surgical plus medical antifungal therapy. We also used meta-analytic techniques to evaluate 22 observational case-series (72 patients) of the 105 reports with two or more patients with definite Candida IE.

RESULTS

We found that in patients who underwent adjunctive surgery there was a lower reported proportion of deaths [prevalence odds ratio (POR)=0.56; 95% confidence interval (CI)=0.16, 1.99)]. Higher mortality was noted in patients treated prior to 1980 (POR=2.03; 95% CI=0.55, 7.61), treated with antifungal monotherapy (POR=1.49; 95% CI=0.39, 5.81), infected with Candida parapsilosis (POR=1.51; 95% CI=0.41, 5.52), or with left-sided endocarditis (POR=2.36; 95% CI=0.55, 10.07).

CONCLUSIONS

Medical antifungal therapy of Candida IE is poorly characterized, and recent antifungal developments lend promise for those patients who cannot undergo surgery.

Candida Tricuspid Endocarditis in a Non-addict

Isolated native non-rheumatic fungal tricuspid valve endocarditis is rarely described in the absence of intravenous drug addiction or use of intracardiac catheters or concomitant cardiac anomalies. Herein, we report a case of tricuspid valve endocarditis in a non-addict, which was successfully treated with valve replacement. The cultures of blood and vegetations revealed Candida Pichia Etschelsii. Candida tricuspid endocarditis must be considered in any patient with tricuspid vegetation, regardless of predisposing factors. </hea

Isolated tricuspid valve endocarditis in nonaddicted patients: a diagnostic challenge

Isolated native nonrheumatic tricuspid valve endocarditis rarely is described in the absence of intravenous drug use, intracardiac catheters, or cardiac anomalies. We diagnosed tricuspid valve endocarditis in two elderly nonaddicted patients with recurrent pulmonary infiltrates, anemia, and microscopic hematuria that occurred during several months and was caused by Gemella morbillorum and Candida glabrata, respectively. We have reviewed 27 other cases of nonaddicted patients with tricuspid valve endocarditis from the literature and discussed etiology, clinical characteristics, and outcome. Mean age was 53.5 years (range, 22 to 74 years old), and 72% had underlying medical conditions. Staphylococcus oureus, Streptococcus bovis, and candida species were the causative organisms in 70% of the cases. Average duration of infection before diagnosis was 9.3 months. We conclude that isolated tricuspid valve endocarditis in nonaddicted patients occurs mainly in the middle-aged and older persons, mimicking chronic illness and community-acquired pneumonia. In the absence of a history of intravenous drug use, diagnostic delays are common. We suggest that right-sided endocarditis must be considered in any patient with the "Tricuspid Syndrome," consisting of recurrent pulmonary events, anemia, and microscopic hematuria. Careful evaluation of prior medical records and clinical course can be very helpful. Echocardiography and serial blood cultures provide the key to diagnosis.

Conservative surgery in multiple cusp involvement in tricuspid valve endocarditis

Tricuspid and mitral valve endocarditis caused by Staphylococcus epidermidis in a 57 year old previously healthy man with no history of drug abuse presented as bi-ventricular failure and multiple episodes of pulmonary emboli. He was treated for four weeks with intravenous antibiotics and had serial echocardiographic assessment of the vegetation on the tricuspid valve. This was followed by mitral valve replacement, local excision of vegetation from all the three cusps of the tricuspid valve, and autologous pericardial reconstruction of these cusps with functional assessment by perioperative transoesophageal echocardiography. Postoperative cardiac function was excellent and serial echocardiographic assessment confirmed satisfactory tricuspid valve function. This is believed to be the first recorded case in which autologous pericardial repair was used to reconstruct all the three cusps in a tricuspid valve after excision of vegetations.