Acute Cardiac Failure due to Intra-Atrial Mass Caused by Zygomycetes in an Immunocompromised Paediatric Patient

Disseminated Cunninghamella bertholletiae mucormycosis with protracted clinical course and formation of a large intra-ventricular mural thrombus

We report the autopsy findings of a case of disseminated mucormycosis caused by Cunninghamella bertholletiae, a rare pathogenic fungus of the family Mucoraceae. The patient was a 49-year-old woman with B-lymphoblastic leukemia with hyperdiploidy, who died of progressive heart failure 4 months after induction chemotherapy successfully brought about complete remission of the leukemia. Granulocyte colony-stimulating factor (G-CSF) had been administered along with anti-neoplastic drugs, and her blood neutrophil count was markedly elevated. Autopsy revealed disseminated mycotic thromboembolism and abscess formation in the heart, lung, liver, kidney, and spleen. The most marked feature was a large mural thrombus in the left ventricle containing numerous fungal hyphae. In the myocardium and disseminated foci in visceral organs, giant cell-rich, fibrotic reactions to the mycotic infection were observed. Both the formation of a large intra-ventricular mural thrombus and giant cell reactions are rare findings in mucormycosis. We considered that the recovery and marked increase in neutrophil count induced by chemotherapy and G-CSF administration prolonged the clinical course and pathologically elicited an atypical, giant cell reaction to the mycotic infection. The prolonged clinical course also contributed to the formation of an unusually large intra-ventricular mural thrombus.

Disseminated Cunninghamella spp. Endocarditis in a Beta-Thalassemia Patient after Asymptomatic COVID-19 Infection

Cunninghamella spp. is a group of fungi belonging to the Mucorales order. Cases of fungal endocarditis are sporadic, but more frequent in immunocompromised patients. COVID-19 (SARS-CoV-2 Infection Disease 2019) infections, prematurity, deferoxamine treatment, iron overload, neutropenia, diabetes, and malignant hemopathies proved to be risk factors for mucormycosis. We present the case of a 7-year-old boy who was treated every three weeks with blood transfusion for major beta-thalassemia, receiving deferoxamine for secondary hemochromatosis. After two weeks with nonspecific respiratory and digestive symptoms, he was admitted for fever, followed by lower limb ischemia and neurological signs. Echocardiography revealed massive endocarditis affecting the mitral and tricuspid valves with embolization phenomena in the brain, lungs, kidney, spleen, and lower limbs. As a particular finding, IgG antibodies for COVID-19 were positive. Emergency cardiac surgery was performed. The mitral valve necessitated replacement with CarboMedics prosthesis. Unfortunately, the patient did not survive. Cunninghamella spp. was confirmed via the PCR analysis of vegetations. Cunninghamella endocarditis in the context of a systemic infection presented as an opportunistic infection affecting a child who had several risk factors. Mucormycosis is challenging to treat, with high mortality. Prophylactic treatment in beta-thalassemia patients with iron-chelator deprivation drugs, such as deferiprone, may help in preventing these particular fungal infections.

Fungal endocarditis in paediatrics: a review of 192 cases (1971-2016)

BACKGROUND

The aims of this article were to review the published literature on fungal endocarditis in children and to discuss the aetiology and diagnosis, with emphasis on non-invasive methods and various treatment regimes.

METHODS

We systematically reviewed published cases and case series of fungal endocarditis in children. We searched the literature, including PubMed and individual references for publications of original articles, single cases, or case series of paediatric fungal endocarditis, with the following keywords: "fungal endocarditis", "neonates", "infants", "child", and "cardiac vegetation".

RESULTS

There have been 192 documented cases of fungal endocarditis in paediatrics. The highest number of cases was reported in infants (93/192, 48%) including 60 in neonates. Of the neonatal cases, 57 were premature with a median gestational age of 27 weeks and median birth weight of 860 g. Overall, 120 yeast - fungus that grows as a single cell - infections and 43 mould - fungus that grows in multicellular filaments, hyphae - infections were reported. With increasing age, there was an increased infection rate with moulds. All the yeast infections were detected by blood culture. In cases with mould infection, diagnosis was mainly established by culture or histology of emboli or infected valves after invasive surgical procedures. There have been a few recent cases of successful early diagnosis by non-invasive methods such as blood polymerase chain reaction (PCR) for moulds. The overall mortality for paediatric fungal endocarditis was 56.25%. The most important cause of death was cardiac complications due to heart failure. Among the various treatment regimens used, none of them was significantly associated with better outcome.

CONCLUSIONS

Non-invasive methods such as PCR tests can be used to improve the chances of detecting and identifying the aetiological agent in a timely manner. Delays in the diagnosis of these infections may result in high mortality and morbidity. No significant difference was noted between combined surgical and medical therapy over exclusively combined medical therapy.

Cardiac disease in a case of precursor B acute lymphoblastic leukaemia with eosinophilia(ALL/Eo)

Acute lymphoblastic leukaemia (ALL) is the most common paediatric malignancy. However, it may rarely associate with eosinophilia. Patients with ALL associated with eosinophilia (ALL/ Eo) have a grave prognosis and higher incidence of cardiac complications compared to standard lymphoblastic leukaemia. Reports of ALL/Eo disclosed a few case with cardiac involvement early in the course of leukaemia. Here, the authors report a case of 13-year-old boy who presented with peripheral eosinophilia, chest pain and a large left ventricular mass early in the course of precursor B- cell ALL associated with eosinophilia. He received multi-agent chemotherapy but succumbed to death 25 days after chemotherapy due to a refractory cardio respiratory failure.