Endomyocardial and pericardial aspergillosis in critically ill patients

A case series of non-valvular cardiac aspergillosis in critically ill solid organ transplant and non-transplant patients and systematic review

INTRODUCTION

Non-valvular cardiac aspergillosis is a rare infection of the pericardium, myocardium or endocardium and is associated with a high mortality. There is a paucity of reports of non-valvular cardiac aspergillosis in critically ill and solid organ transplant (SOT) patients. The majority of cases have been reported in haemato-oncology patients, some of whom have undergone a bone marrow transplant.

OBJECTIVES

We describe four cases affected by non-valvular cardiac aspergillosis in the intensive care setting including a systematic review of this extremely rare infection which is associated with high mortality.

RESULTS

All four-patients died but presented with varying clinical, radiological and microbiological evidence of the disease. Three patients presented following complications after solid organ transplantation, two in the context of acute liver failure and emergency liver transplant and one several years after a double lung transplant. The last patient presented with necrotising gall stone pancreatitis, multi-organ failure and subsequently a prolonged intensive care unit (ICU) stay. On review of the literature, January 1955 to July 2019, 45 cases were identified, with different risk factors, clinical and radiological manifestations, treatment regimen and outcome.

CONCLUSION

Antemortem diagnosis of cardiac aspergillosis is difficult and rare, with no cases reporting positive blood culture results. Galactomannan serology has poor sensitivity in solid organ transplant patients, further reduced by prophylactic antimicrobial treatment, which is common in the ICU setting especially post-transplant patients. Due to the scarcity of cases, treatment is extrapolated from invasive aspergillosis management, with emphasis on early treatment with combination therapy.

Unusual Presentation of Aspergillus Pericarditis: A Case Report

Cardiac aspergillosis is a rare fungal infection that affects the heart and/or pericardium of immunocompromised patients. Here, the authors report a rare case of a 36-year-old female with aspergillus pericarditis. The patient was diagnosed with infective endocarditis and splenic infarction and treated with emergency splenectomy and double-valve replacement surgery. During the surgery, a fibropurulent pericardial tissue was found and excised. The culture report of the tissue confirmed the diagnosis of aspergillus pericarditis. The patient was successfully managed with intravenous voriconazole. Aspergillus do not usually infect the pericardium and such infections are rarely detected premortem, especially during a cardiac surgery. In this report, the infection was accidentally detected during the double-valve surgery. The authors conclude that because of its nonspecific clinical manifestations, a high degree of clinical suspicion is required for the early diagnosis and treatment of aspergillus pericarditis.