Native Valve Aspergillus Endocarditis Complicating Lung Transplantation

Native-Valve Aspergillus Endocarditis: Case Report and Literature Review

Aspergillus endocarditis represents the second etiological cause of prosthetic endocarditis following Candida spp. On the other hand, native-valve endocarditis due to Aspergillus are anecdotally reported with increasing numbers in the last decade due to new diagnostic technologies such as polymerase chain reaction (PCR) on samples like valve tissue or entire blood. We performed a review of the literature presenting one case report observed at Pisa University Hospital. Seventy-four case reports have been included in a period between 1950-2022. Immunocompromised status (patients with solid tumor/oncohematological cancer or transplanted patients) was confirmed to be the main risk factor for this rare opportunistic infection with a high rate of metastatic infection (above all, central nervous system) and mortality. Diagnosis relies on serum galactomannan and culture with PCR on valve tissue or whole blood. Cardiac surgery was revealed to be a life-saving priority as well as appropriate antifungal therapy including b-liposomal amphotericin or new triazoles (isavuconazole). The endocarditis team, facing negative blood culture endocarditis affecting an immunocompromised patient, should investigate this difficult-to-treat pathogen.

A Repertoire of Clinical Non-Dermatophytes Moulds

Humans are constantly exposed to micromycetes, especially filamentous fungi that are ubiquitous in the environment. In the presence of risk factors, mostly related to an alteration of immunity, the non-dermatophyte fungi can then become opportunistic pathogens, causing superficial, deep or disseminated infections. With new molecular tools applied to medical mycology and revisions in taxonomy, the number of fungi described in humans is rising. Some rare species are emerging, and others more frequent are increasing. The aim of this review is to (i) inventory the filamentous fungi found in humans and (ii) provide details on the anatomical sites where they have been identified and the semiology of infections. Among the 239,890 fungi taxa and corresponding synonyms, if any, retrieved from the Mycobank and NCBI Taxonomy databases, we were able to identify 565 moulds in humans. These filamentous fungi were identified in one or more anatomical sites. From a clinical point of view, this review allows us to realize that some uncommon fungi isolated in non-sterile sites may be involved in invasive infections. It may present a first step in the understanding of the pathogenicity of filamentous fungi and the interpretation of the results obtained with the new molecular diagnostic tools.

Infective endocarditis in patients with solid organ transplantation. A nationwide descriptive study

BACKGROUND

Solid organ transplantation (SOT) implies immunosuppression and frequent health care contact. Our aim was to compare the characteristics of patients with infective endocarditis (IE) and SOT against those without SOT.

METHODS

We used data from the Spanish Collaboration on Endocarditis during the period 2008-2018.

RESULTS

We identified 4794 cases of IE, 85 (1.8%) in SOT (56 kidney, 18 liver, 8 heart, 3 lung). Thirteen patients with other transplantation types (bone marrow, hematopoietic precursors, and cornea) were excluded from the analysis. Compared with patients without SOT, patients with SOT had lower median age (61 vs. 69 years, p<0.001), more comorbidities (mean age-adjusted Charlson index 5.7±2.9 vs. 4.9±2.9, p=0.004), a lower prevalence of native valvular heart disease (29.4 vs. 45.4%, p=0.003), more in-hospital and healthcare-related IE (70.5% vs. 36.3%, p<0.001) and staphylococcal etiology (57.7% vs. 39.7%, p=0.001). Patients with SOT had more frequent kidney function worsening (47.1% vs. 34.6%, p=0.02), septic shock (25.9% vs. 12.1 %, p<0.001), sepsis (27.1% vs. 17.2%, p=0.02), and less surgery indication (54.1% vs 66.3%, p=0.02) and surgery (32.9% vs. 46.3%, p=0.01) than patients without SOT. There were no significant differences in mortality: inhospital (30.6% SOT vs. 25.6% without SOT, p=0.31), 1-year (38.8% SOT vs. 31.9% without SOT, p=0.18).

CONCLUSIONS

Most IE in SOT recipients are nosocomial and over 70% are health care-related. Half have previously normal heart valves and almost 60% are due to Staphylococcus spp. infections. Mortality seems to be similar to non-SOT counterparts.

Fungal endocarditis in transplant recipients: A systematic review

BACKGROUND

Invasive fungal infections remain a major cause of morbidity and mortality in transplant recipients. Moreover, Fungal Infective Endocarditis (FIE) is a rare infection that carries a higher mortality than bacterial IE in normal host, while in transplant recipients may be even higher. The purpose of this study was to systemically review all published cases of FIE in solid organ and allogeneic bone marrow transplant recipients, describe the epidemiology, microbiology, clinical characteristics, treatment and outcomes of these infections, and to identify risk factors for mortality by FIE.

METHODS

A systematic review of PubMed, Scopus and Cochrane Library (through 20 May 2020) for studies providing epidemiological, clinical, microbiological and treatment data and outcomes of FIE in transplant recipients was performed.

RESULTS

A total of 60 studies, containing data of 72 patients, were included. The most common transplants were those of the kidney and the liver, while the commonest causative pathogen was Aspergillus. Mitral valve was the commonest infected intracardiac site, followed by mural endocardium. Diagnosis was made with transthoracic echocardiography in 44.3%, while the diagnosis was made at autopsy in 37.3%. Embolic phenomena were the commonest clinical presentation, followed by fever, heart failure and endophthalmitis. Amphotericin B, voriconazole and caspofungin were the commonest antifungals used for treatment of FIE. Clinical cure was noted in 26.9%, while overall mortality was 78.6%. Amphotericin B or caspofungin use was negatively associated with overall mortality.

CONCLUSIONS

This systematic review thoroughly describes IE in transplant recipients and provides information on epidemiology, clinical presentation, treatment and outcomes.

Aspergillus flavus native valve endocarditis following combined liver and renal transplantation: Case report and review of the literature

Aspergillus endocarditis is a rare infection that occurs most commonly in patients with prior cardiac surgery but cases in post-transplant recipients without prior cardiac surgery have been reported. Diagnosis is often delayed and requires high index of suspicion. We here report a case of Aspergillus endocarditis in solid organ transplant recipient.

Aspergillus endocarditis: a review of the literature

We present a case of cardiac device-related Aspergillus endocarditis in a patient with a pacemaker and an allogeneic bone marrow transplant to segue into a review of the Aspergillus endocarditis literature. Aspergillus endocarditis should be suspected in patients with underlying immunosuppression, negative cultures, and a vegetation on echocardiography. Diagnosis ultimately requires confirmation by tissue histology and culture. The optimal treatment approach often requires aggressive surgical debridement in conjunction with prolonged antifungal therapy.