Aspergillus endocarditis in lung transplant recipients: case report and literature review

Endocarditis caused by Aspergillus fumigatus in a patient 9 months after COVID-19 infection recovery: a case report and review of the literature

BACKGROUND

Aspergillus spp. are among the fungal pathogens that can cause life-threatening infections in patients with a history of COVID-19.

CASE PRESENTATION

We present the case of a 58-year-old Iranian woman with post-COVID-19 Aspergillus fumigatus endocarditis complicated by numerous thromboembolisms. She underwent mitral valve replacement surgery and multiple lower extremity embolectomies and was treated with voriconazole, which led to her final recovery.

CONCLUSIONS

Aspergillus endocarditis should be considered in any patient with suspected endocarditis who has a history of COVID-19 infection and does not respond to routine antibiotic and antifungal therapy, as COVID-19 interferes with proper immune function, and lack of underlying cardiac conditions and immunodeficiencies does not preclude the diagnosis. Culture and histopathological evaluation of vegetations and emboli, as well as PCR, can confirm the diagnosis. Early initiation of antifungal therapy and surgical removal of infected valves and emboli can improve prognosis in patients with Aspergillus endocarditis.

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.

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.

Potential benefit of combination antifungal therapy in Aspergillus endocarditis

Aspergillus endocarditis (AE) is a rare condition with a mortality rate greater than 60%. While it is generally accepted that both antifungal therapy and surgery are necessary for survival, the optimal antifungal regimen is unclear. A 62-year-old man was diagnosed with AE of a prosthetic aortic valve, complicated by cerebral emboli. He underwent debridement of the aortic valve abscess and valve replacement, and was managed with a combination of liposomal amphotericin B and voriconazole for 7 weeks followed by long-term suppressive azole therapy. He remained well at follow-up 18 months later. Data from a review of case reports published between 1950 and 2010 revealed greater survival rates in patients managed with two or more antifungals as opposed to single agent therapy. We provide an updated literature review with similar findings, suggesting that dual agent antifungal therapy should be considered in patients with AE.

Infections in Heart, Lung, and Heart-Lung Transplantation

Half a century has passed since the first orthotopic heart transplant took place. Surgical innovations allowed for heart, lung, and heart-lung transplantation to save lives of patients with incurable chronic cardiopulmonary conditions. The complexity of the surgical interventions, chronic host health conditions, and antirejection immunosuppressive medications makes infectious complications common. Infections have remained one of the main barriers for successful transplantation and a source of significant morbidity and mortality. Recognition of infections and its management in this setting require outstanding clinical skills since transplant recipients may not exhibit classic signs or symptoms of disease, and laboratory work has some pitfalls. The prevention, identification, and management of infectious diseases complications in this population are a priority to undertake to improve the medical outcomes of transplantation. Herein, we reviewed the historical aspects, epidemiology, and prophylaxis of infections in heart, lung, and heart-lung transplantation. We also discuss the most prevalent organisms affecting the host and the organ systems involved.

Aspergillus fumigatus endocarditis in an indigenous Australian male without classic risk factors

Aspergillus endocarditis is rare with most cases occurring in immunosuppressed patients. We present the case of an “immunocompetent” Indigenous Australian male with culture confirmed Aspergillus brain abscesses complicating bilateral endocarditis. The reported mortality rate for Aspergillus endocarditis approaches 100%. Despite sub-optimal therapy this patient survived beyond expectation.

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.

The neurology of solid organ transplantation

Transplantation is the rescue treatment for end-stage organ failure with more than 110,000 solid organs transplantations performed worldwide annually. Recent advances in transplantation procedures and posttransplantation management have improved long-term survival and quality of life of transplant recipients, shifting the focus from acute perioperative critical care needs toward long-term chronic medical problems. Neurologic complications affect up to 30-60 % of solid organ transplant recipients. Common etiologies include opportunistic infections and toxicities of antirejection medications, and wide spectrum of toxic and metabolic disturbances. Most complications are common to all allograft types, but some are relatively specific for individual allograft types (e.g., central pontine myelinolysis in liver transplant recipients). Close collaboration between neurologists and other transplant team members is essential for effective management. Early recognition of complications and accurate diagnosis leading to timely treatment is essential to reduce the morbidity and improve the overall transplant outcome.