Aspergillus endocarditis: Diagnostic criteria and predictors of outcome, A retrospective cohort study

Devastating fungal endocarditis involving ascending aorta in a patient with a history of aortic valve replacement: a case report

BACKGROUND

Fungal endocarditis is a rare but serious condition associated with high mortality rates. Various predisposing factors contribute to its occurrence, such as underlying cardiac abnormalities, cardiac surgeries, prosthetic cardiac devices, and central venous catheters. Diagnosing fungal endocarditis, particularly Aspergillus, poses challenges, often complicated by negative blood cultures.

CASE PRESENTATION

This report details a case of extensive ascending aorta involvement in Aspergillus endocarditis (AE) in a 24-year-old man with a history of bioprosthesis aortic valve replacement (AVR). Three months post-AVR, he presented with pericardial effusion and aortic rupture, leading to a redo biological valved conduit aortic root replacement (Bentall surgery). Despite the intervention, the tubular graft exhibited extensive Aspergillus involvement, resulting in graft disruption and significant peri-aortic infection. A second redo procedure involving aortic homograft root replacement was performed. Unfortunately, the patient succumbed two days after the surgery.

CONCLUSION

A combined approach of medical and surgical therapies is recommended to manage fungal endocarditis. Despite efforts, the mortality rate associated with Aspergillus endocarditis remains unacceptably high, with no significant difference observed between combination therapy and antifungal treatment alone. Further research is essential to explore novel therapeutic strategies and improve outcomes for patients with this challenging condition.

Hematologic Parameters as Predictors of Long-Term Mortality in Infective Endocarditis Patients

BACKGROUND Infective endocarditis (IE) is an endothelial infection that is associated with high mortality and morbidity rates. Early and accurate risk prediction is important in patients with IE. Neutrophil-to-lymphocyte ratio (NLR), which is one of the hematological parameters that can be performed anywhere and is easily accessible, is a predictor of poor prognosis in many infectious and cardiovascular diseases. This study aimed to evaluate the association between laboratory parameters and 3-year mortality in 155 patients with infective endocarditis at a single center in Turkey. MATERIAL AND METHODS We retrospectively analyzed the clinical and echocardiographic data of 155 adult patients with definite IE according to the modified Duke Criteria, and we analyzed all laboratory results, such as hemoglobin, white blood cell, neutrophil, lymphocyte, platelet, platelet distribution width, NLR, urea, creatinine, albumin, procalcitonin, and blood culture results. RESULTS The median follow-up time was 341 days (range, 2-4003 days). The out-of-hospital mortality rate was 31.6%. Among the discharged patients (n=106), there were 46 non-survivors, with an out-of- hospital mortality rate of 43.4%. The overall mortality rate was 61.3%. During the follow-up, the 1-year mortality rate was 47.1% and the 3-year mortality rate was 54.8%. We detected significant differences in the admission values of NLR between the patients with and without 3-year mortality (P<0.001). CONCLUSIONS The NLR on admission to a tertiary center was independently associated with 3-year mortality in IE patients (P<0.001). NLR is a parameter that can be obtained from a simple, widely available and inexpensive hemagroma as a useful marker in predicting long-term mortality in IE.

Fungal Endocarditis: Pathophysiology, Epidemiology, Clinical Presentation, Diagnosis, and Management

Fungal endocarditis accounts for 1% to 3% of all infective endocarditis cases, is associated with high morbidity and mortality (>70%), and presents numerous challenges during clinical care. Candida spp. are the most common causes of fungal endocarditis, implicated in over 50% of cases, followed by Aspergillus and Histoplasma spp. Important risk factors for fungal endocarditis include prosthetic valves, prior heart surgery, and injection drug use. The signs and symptoms of fungal endocarditis are nonspecific, and a high degree of clinical suspicion coupled with the judicious use of diagnostic tests is required for diagnosis. In addition to microbiological diagnostics (e.g., blood culture for Candida spp. or galactomannan testing and PCR for Aspergillus spp.), echocardiography remains critical for evaluation of potential infective endocarditis, although radionuclide imaging modalities such as 18F-fluorodeoxyglucose positron emission tomography/computed tomography are increasingly being used. A multimodal treatment approach is necessary: surgery is usually required and should be accompanied by long-term systemic antifungal therapy, such as echinocandin therapy for Candida endocarditis or voriconazole therapy for Aspergillus endocarditis.

Rare case of infective endocarditis from invasive aspergillosis encasing the pulmonary valve: a case report

Background

Aspergillus endocarditis is a rare cause of infective endocarditis and requires high index of suspicion for diagnosis.

Case summary

We describe a case of a 50-year-old man with history of metastatic thymoma on immunosuppression (gemcitabine and capecitabine) who presented with progressive dyspnoea. Echocardiography and computed tomography (CT) of chest showed filling defect in the pulmonary artery. The initial differential diagnosis was of pulmonary embolism and metastatic disease. The mass was subsequently excised, which revealed a diagnosis of Aspergillus endocarditis of the pulmonary valve. Unfortunately, he passed away despite medical treatment with antifungal therapy after surgery.

Discussion

Aspergillus endocarditis should be suspected in immunosuppressed hosts with negative blood cultures and large vegetations on echocardiography. Diagnosis is made by tissue histology but may be difficult or delayed. Optimal treatment involves aggressive surgical debridement and prolonged antifungal therapy; prognosis is poor with high mortality.

Pacemaker Associated Aspergillus fumigatus Endocarditis: A Case Report

Aspergillus endocarditis (AE) is a highly fatal infection that can occur in heart valve replacement, pacemaker implantation and other heart surgeries, and early recognition and sufficient diagnosis are challenging. Here, we report the case of a 68-year-old male with a history of dilated cardiomyopathy and pacemaker implantation who had a repeated fever with failed antibacterial treatment and sterile blood culture. He developed endocarditis, and the culture and biopsy of vegetation tissue showed the abundant presence of septate hyphae, which was subsequently identified as Aspergillus fumigatus by internal transcribed spacer (ITS) sequencing. Although the patient had serious side effects from voriconazole, he had a good prognosis following surgery and prolonged caspofungin antifungal therapy of 42 consecutive days. We discuss the diagnosis and treatment strategy of AE, and recommend galactomannan assays and next-generation sequencing for a timely diagnosis. Early surgical intervention combined with prompt antifungal therapy appears significant for survival.

Case Report: Culture-negative Prosthetic Valve Endocarditis

BACKGROUND

Prosthetic valve endocarditis can be difficult to diagnose and cause significant morbidity and mortality, especially when no culture data are available to guide therapy. Transthoracic and transesophageal echocardiograms, the studies of choice for initial endocarditis evaluation, can be less reliable due to artifact and post-surgical changes. Some less common forms of endocarditis may be difficult to culture and, due to their fastidious nature, may delay the identification of causative organisms. Given the lack of directed antimicrobial treatment, culturenegative prosthetic valve endocarditis is specifically difficult. A wide differential diagnosis is critical to make a timely diagnosis and initiate treatment.

CASE PRESENTATION

We present a case of a patient presenting with dyspnea which was found to have culture-negative endocarditis requiring mitral and aortic valve replacement that ultimately was complicated with culture-negative prosthetic valve endocarditis. Identifying a culprit organism made appropriate and timely antimicrobial treatment difficult, ultimately resulting in the patient dying from endocarditis complications.

CONCLUSION

A high index of suspicion is needed when managing infective endocarditis, especially when prosthetic valves are involved. Diagnostic accuracy of cultures and echocardiography may be reduced when dealing with prosthetic valve endocarditis; thus, alternative methods of diagnosis may be required to make a timely diagnosis of causative organisms.

Post-COVID-19 fatal Aspergillus endocarditis: A case report

BACKGROUND

Aspergillus endocarditis (AE) is a rare fatal infection. The infection is often reported in patients with prosthetic heart valves, immunosuppressed, broad-spectrum antimicrobial use regimens, and drug abusers.

METHODS

Herein, we report a rare case of native mitral valve AE in a 63-year-old man, with a probable COVID-19-associated invasive pulmonary aspergillosis nine months ago treated with antifungals.

RESULTS

In the last admission, the lethargy, neurological deficit, and septic-embolic brain abscess in brain MRI led to suspicion of infective endocarditis. Transesophageal two-dimensional echocardiography and color Doppler flow velocity mapping showed a large highly mobile mass destroying leaflet and severe mitral regurgitation. The Surgical valve replacement is performed. The surgical valve replacement is performed. Direct microscopic examination and culture of the explanted and vegetative mass revealed Aspergillus section Fumiagati confirmed by molecular method. Despite the administration of voriconazole and transient improvement the patient expired.

CONCLUSION

As AE is a late consequence of COVID-19-associated invasive pulmonary aspergillosis, therefore, long-term follow-up of invasive aspergillosis, and prompt diagnosis of surgical and systemic antifungal therapy treatment, are warranted to provide robust management.

Non-valvular Infective Endocarditis Caused by Sarocladium kiliense in an Immunocompromised Patient with Aplastic Anemia

Sarocladium kiliense is ubiquitous in the human environment and is an emerging opportunistic pathogen, especially among immunocompromised hosts. A 77-year-old man diagnosed with aplastic anemia suffered from non-valvular endocarditis. After he passed away, fungal hyphae were observed in several lesions on a postmortem examination. Polymerase chain reaction (PCR) and a DNA sequence analysis revealed S. kiliense as the causative organism. This is the first case report of non-valvular fungal endocarditis caused by S. kiliense identified by PCR and a DNA sequence analysis in an immunocompromised patient. Although rare, invasive fungal infection caused by S. kiliense should be considered in immunocompromised hosts.

A case of pacemaker associated Aspergillus fumigatus endocarditis

The use of cardiovascular implantable electronic devices (CIED) is associated with improved quality of life and decreased fatal outcomes in patients with cardiac dysfunctions. As with all foreign devices that are inserted or implanted in the body, CIED also carries the risk of device-related infections. Infections account for <2% of the complications associated with CIED, and only about 2% of these are secondary to a fungal pathogen. The first case of Aspergillus endocarditis secondary to a transvenous pacing lead was reported in the 1980s, and a limited number of cases have been documented in the literature since then. Aspergillus endocarditis is a highly fatal disease and establishing the diagnosis sufficiently early is challenging. We here report a case of Aspergillus endocarditis secondary to permanent pacemaker insertion which was successfully treated following the establishment of the diagnosis using imaging studies and galactomannan assay.

Aspergillus Endocarditis in the recent years, report of cases of a multicentric national cohort and literature review

OBJECTIVES

1) To describe the incidence, clinical characteristics, treatment and outcome of Aspergillus Endocarditis (AE) in a nationwide multicentric cohort (GAMES). 2) To compare the AE cases of the GAMES cohort, with the AE cases reported in the literature since 2010. 3) To identify variables related to mortality.

METHODS

We recruited 10 AE cases included in the GAMES cohort (January 2008-December 2018) and 51 cases from the literature published from January 2010-July 2019.

RESULTS

4.528 patients with Infectious Endocarditis (IE) were included in the GAMES cohort, of them 10 (0.2%) were AE. After comparing our 10 cases with the 51 of the literature, no differences were found. Analyzing the 61 AE cases together, 55.7% were male, median age 45 years. Their main underlying conditions were: prosthetic valve surgery (34.4%) and solid organ transplant (SOT) (19.7%). Mainly affecting mitral (36.1%) and aortic valve (29.5%). Main isolated species were: A.fumigatus (47.5%) and A.flavus (24.6%). Embolisms occurred in 54%. Patients were treated with antifungals (90.2%), heart surgery (85.2%) or both (78.7%). Overall, 52.5% died. A greater mortality was observed in immunosuppressed patients (59.4% vs 24.1%, OR=4.09, 95%CI=1.26-13.19, p=0.02) and lower mortality was associated with undergoing cardiac surgery plus azole therapy (28.1% vs 65.5%, OR=0.22, 95%CI=0.07-0.72, p=0.01).

CONCLUSIONS

AE accounts for 0.2% of all IE episodes of a national multicentric cohort, mainly affecting patients with previous valvular surgery or SOT recipients. Mortality remains high especially in immunosuppressed hosts and azole-based treatment combined with surgical resection are related to a better outcome.

Invasive aspergillosis and endocarditis

INTRODUCTION

Aspergillusfumigatus can cause a systemic infection called invasive aspergillosis causing pulmonary and extra-pulmonary damage. Aspergillus endocarditis (AE) is a relatively rare disease but can be life-threatening.

CASE REPORTS

We report here on five cases of endocarditis due to invasive aspergillosis: a 58-year-old man receiving immunosuppressive medication following a kidney graft, a 58-year-old man undergoing chemotherapy for chronic lymphocytic leukaemia, a 55-year-old man receiving corticosteroids for IgA vasculitis, a 52-year-old HIV-infected woman under no specific treatment and a 17-year-old boy under immunosuppressive therapy for auto-immune chronic neutropenia.

DISCUSSION

Aspergillus accounts for 25-30% of fungal endocarditis and 0.25% to 8.5% of all cases of infectious endocarditis. Aspergillus endocarditis results from invasion of the lung arterioles by hyphae and blood dissemination. It is associated with a very high mortality rate (42-68%). Diagnosing Aspergillus endocarditis is mainly problematic because blood cultures are almost always negative, and fever may be absent. Immunosuppression, haematological malignancies, recent cardiothoracic surgery, negative blood cultures with endocarditis and/or systemic or pulmonary emboli are predictors of AE. In the setting of endocarditis, some clinical characteristics may raise early suspicions of aspergillosis rather than a non-fungal agent: no fever, vegetations affecting the mitral valve, non-valve or aortotomy sites, aortic abscess or pseudo-aneurysm. The identification of invasive aspergillosis is based on a chest CT scan, microscopy/culture or other serological and molecular tests. The treatment of Aspergillus endocarditis requires triazole antifungal drugs, and frequently additional surgical debridement.

CONCLUSION

Aspergillus endocarditis is rare but is associated with a very high mortality rate. Knowledge of its predictive factors and key clinical features can help to differentiate aspergillosis from non-fungal endocarditis and may enable improved survival rates.

Aspergillus flavus endocarditis and meningitis in a child with marfan syndrome

Background and Purpose:

Aspergillus species are implicated as the etiology of approximately 26% of endocarditis cases. Central nervous system aspergillosis is a life-threatening condition that has a mortality rate of 80%.

Case report:

Herein, we report a four– year- old female who was admitted to the pediatric infectious ward due to a fever of unknown origin in January 2020. She was a known case of Marfan syndrome with a family history of this syndrome in her mother. The species was identified using (PCR) and the antifungal susceptibility test was performed using four antifungal agents based on the Clinical and Laboratory Standards Institute M38 3rd edition. Fluconazole-resistant Aspergillus flavus was identified to be responsible for endocarditis and meningitis as well as fever of unknown origin.

Conclusion:

The clinicians should be aware and consider fungal endocarditis in blood culture-negative endocarditis even in patients with no significant risk factor when antibiotic therapy fails.

Fatal Prosthetic Valve Endocarditis Due to Aspergillus flavus in a Diabetic Patient

Aspergillus endocarditis (AE) accounts for a-quarter of all fungal endocarditis, mainly in immunocompromised hosts prior to heart-valve surgery with high mortality, even with treatment. Herein, we report a rare case of AE in a diabetic 60-year-old woman with a history of redo mitral valve prosthesis suspecious of acute endocarditis. She underwent second redo surgical mitral valve replacement in combination with mechanical aortic valve replacement. Blood cultures were negative. The explanted valve and vegetation were subjected to identification. Grown colonies were identified as Aspergillus flavus, based on conventional and molecular methods. Despite the administration of liposomal amphotericin B and improvement in her general condition shortly after initiation of therapy, the patient passed away. As AE is a late consequence of redo prosthetic valve replacement, extended follow-up, early diagnosis, repeating valve-replacement surgeries, and timely selective antifungal treatments are warranted.

A comparison of different antibiotic regimens for the treatment of infective endocarditis

BACKGROUND

Infective endocarditis is a microbial infection of the endocardial surface of the heart. Antibiotics are the cornerstone of treatment, but due to the differences in presentation, populations affected, and the wide variety of micro-organisms that can be responsible, their use is not standardised. This is an update of a review previously published in 2016.

OBJECTIVES

To assess the existing evidence about the clinical benefits and harms of different antibiotics regimens used to treat people with infective endocarditis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase Classic and Embase, LILACS, CINAHL, and the Conference Proceedings Citation Index - Science on 6 January 2020. We also searched three trials registers and handsearched the reference lists of included papers. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) assessing the effects of antibiotic regimens for treating definitive infective endocarditis diagnosed according to modified Duke's criteria. We considered all-cause mortality, cure rates, and adverse events as the primary outcomes. We excluded people with possible infective endocarditis and pregnant women.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, 'Risk of bias' assessment, and data extraction in duplicate. We constructed 'Summary of findings' tables and used GRADE methodology to assess the quality of the evidence. We described the included studies narratively.

MAIN RESULTS

Six small RCTs involving 1143 allocated/632 analysed participants met the inclusion criteria of this first update. The included trials had a high risk of bias. Three trials were sponsored by drug companies. Due to heterogeneity in outcome definitions and different antibiotics used data could not be pooled. The included trials compared miscellaneous antibiotic schedules having uncertain effects for all of the prespecified outcomes in this review. Evidence was either low or very low quality due to high risk of bias and very low number of events and small sample size. The results for all-cause mortality were as follows: one trial compared quinolone (levofloxacin) plus standard treatment (antistaphylococcal penicillin (cloxacillin or dicloxacillin), aminoglycoside (tobramycin or netilmicin), and rifampicin) versus standard treatment alone and reported 8/31 (26%) with levofloxacin plus standard treatment versus 9/39 (23%) with standard treatment alone; risk ratio (RR) 1.12, 95% confidence interval (CI) 0.49 to 2.56. One trial compared fosfomycin plus imipenem 3/4 (75%) versus vancomycin 0/4 (0%) (RR 7.00, 95% CI 0.47 to 103.27), and one trial compared partial oral treatment 7/201 (3.5%) versus conventional intravenous treatment 13/199 (6.53%) (RR 0.53, 95% CI 0.22 to 1.31). The results for rates of cure with or without surgery were as follows: one trial compared daptomycin versus low-dose gentamicin plus an antistaphylococcal penicillin (nafcillin, oxacillin, or flucloxacillin) or vancomycin and reported 9/28 (32.1%) with daptomycin versus 9/25 (36%) with low-dose gentamicin plus antistaphylococcal penicillin or vancomycin; RR 0.89, 95% CI 0.42 to 1.89. One trial compared glycopeptide (vancomycin or teicoplanin) plus gentamicin with cloxacillin plus gentamicin (13/23 (56%) versus 11/11 (100%); RR 0.59, 95% CI 0.40 to 0.85). One trial compared ceftriaxone plus gentamicin versus ceftriaxone alone (15/34 (44%) versus 21/33 (64%); RR 0.69, 95% CI 0.44 to 1.10), and one trial compared fosfomycin plus imipenem versus vancomycin (1/4 (25%) versus 2/4 (50%); RR 0.50, 95% CI 0.07 to 3.55). The included trials reported adverse events, the need for cardiac surgical interventions, and rates of uncontrolled infection, congestive heart failure, relapse of endocarditis, and septic emboli, and found no conclusive differences between groups (very low-quality evidence). No trials assessed quality of life.

AUTHORS' CONCLUSIONS

This first update confirms the findings of the original version of the review. Limited and low to very low-quality evidence suggests that the comparative effects of different antibiotic regimens in terms of cure rates or other relevant clinical outcomes are uncertain. The conclusions of this updated Cochrane Review were based on few RCTs with a high risk of bias. Accordingly, current evidence does not support or reject any regimen of antibiotic therapy for the treatment of infective endocarditis.

An unusual case of Aspergillus endocarditis of native aortic valve following ECMO

Fungal endocarditis following Extracorporeal membrane oxygenation (ECMO) is rare and very rarely reported. Though rare it has a high mortality rate. A 49-year-old male patient who had venovenous ECMO presented with aortic valve endocarditis after 40 days. He underwent sutureless bioprosthehtic valve placement and debridement of abscess. Abscess fluid grew aspergillus species and was started on dual antifungal intravenous amphotericin and variconazole. He was discharged after 1 month with oral variconazole. Incidence of aseptic endocarditis (AE) has been on rise due to increase in invasive procedures. Blood culture is mostly sterile, and fever may be absent. Abscess debridement and aggressive dual antifungal treatment helped our patient in his road to recovery. In current era with increasing use of ECMO, newer rarer complications should be kept in mind. High index of suspicion is required for diagnosing fungal endocarditis after ECMO.

Partial oral antibiotic therapy is non-inferior to intravenous therapy in non-critically ill patients with infective endocarditis : Review and meta-analysis

Background

Antimicrobial therapy is a cornerstone in the treatment of infective endocarditis (IE). Typically, intravenous (i.v.) therapy is given for 6 weeks or longer, leading to prolonged hospital stays and high costs. Several trials evaluating the efficacy of partial oral therapy (POT) have been published. This article aimed to review and meta-analyze studies comparing i.v. therapy versus POT in non-critically ill patients suffering from IE.

Methods

A structured database search (based on PRISMA guidelines) regarding POT versus i.v. therapy in IE was conducted using PubMed/Medline. Primary endpoint was all-cause mortality and a secondary endpoint IE relapse. Risk rates were calculated using a random effects model (DerSimonian and Laird). Heterogeneity was assessed using the I² statistics.

Results

After screening 1848 studies at title and abstract levels, 4 studies were included. A total of 765 patients suffered from primary left-sided IE, whereas right-sided IE was observed in 72 patients. Mortality rates were lower in POT versus i.v. therapy (risk ratio [RR] 0.38, 95% confidence interval, confidence interval [CI] 0.20–0.74; p = 0.004; I² 0%). IE relapse rates were similar (RR 0.63, 95% CI 0.29–1.37; p = 0.24; I² 0%).

Conclusion

Data comparing POT with standard care in IE is limited and to date only one sufficiently powered stand-alone trial exists to support its use. In this meta-analysis POT was non-inferior to i.v. therapy with respect to mortality and IE relapse in non-critically ill patients suffering from both left-sided and right-sided IE. These findings indicate that POT is a feasible treatment strategy in selected patients suffering from IE but further validation in future studies will be required.

Gender differences in clinical features and complications of infective endocarditis: 11-year experience of a single institute in Egypt

BACKGROUND

No data exists about the gender differences among patients with infective endocarditis (IE) in Egypt. The objective was to study possible gender differences in clinical profiles and outcomes of patients in the IE registry of a tertiary care center over 11 years.

RESULTS

The IE registry included 398 patients with a median age of 30 years (interquartile range, 15 years); 61.1% were males. Males were significantly older than females. Malignancy and recent culprit procedures were more common in females while chronic liver disease and intravenous drug abuse (IVDU) were more in males. IE on top of structurally normal hearts was significantly more in males (25.6% vs 13.6%, p = 0.005) while rheumatic valvular disease was more common in females (46.3% vs 29.9%, p = 0.001). There was no difference in the duration of illness before presentation to our institution. The overall complication rate was high but significantly higher in females. However, there were no significant differences in the major complications: mortality, fulminant sepsis, renal failure requiring dialysis, heart failure class III-IV, or major cerebrovascular emboli.

CONCLUSION

In this registry, IE occurred predominantly in males. Females were significantly younger at presentation. History of recent culprit procedures was more common in females while IVDU was more common in males who had a higher incidence of IE on structurally normal hearts. The overall complication rate was higher in women. IE management and its outcomes were similar in both genders.

Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) as independent predictors of outcome in infective endocarditis (IE)

Background

Early and accurate risk assessment is an important clinical demand in patients with infective endocarditis (IE). The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are independent predictors of prognosis in many infectious and cardiovascular diseases. Very limited studies have been conducted to evaluate the prognostic role of these markers in IE.

Results

We analyzed clinical, laboratory, and echocardiographic data and outcomes throughout the whole period of hospitalization for a total of 142 consecutive patients with definitive IE.

The overall in-hospital mortality was 21%. Major complications defined as central nervous system embolization, fulminant sepsis, acute heart failure, acute renal failure, and major artery embolization occurred in 38 (27%), 34 (24%), 32 (22.5%), 40 (28%), and 90 (63.4%) patients, respectively.

The NLR, total leucocyte count (TLC), neutrophil percentage, creatinine, and C-reactive protein (CRP) level obtained upon admission were significantly higher in the mortality group [p ≤ 0.001, p = 0.008, p = 0.001, p = 0.004, and p = 0.036, respectively].

A higher NLR was significantly associated with fulminant sepsis and major arterial embolization [p = 0.001 and p = 0.028, respectively].

The receiver operating characteristic (ROC) curve of the NLR for predicting in-hospital mortality showed that an NLR > 8.085 had a 60% sensitivity and an 84.8% specificity for an association with in-hospital mortality [area under the curve = 0.729, 95% confidence interval (CI) 0.616–0.841; p = 0.001]. The ROC curve of the NLR for predicting severe sepsis showed that an NLR > 5.035 had a 71.8% sensitivity and a 68.5% specificity for predicting severe sepsis [area under the curve 0.685, 95% CI 0.582–0.733; p = 0.001].

The PLR showed no significant association with in-hospital mortality or in-hospital complications.

Conclusion

A higher NLR, TLC, neutrophil percentage, creatinine level, and CRP level upon admission were associated with increased in-hospital mortality and morbidity in IE patients. Furthermore, a lower lymphocyte count/percentage and platelet count were strong indicators of in-hospital mortality among IE patients.

Calculation of the NLR directly from a CBC upon admission may assist in early risk stratification of patients with IE.

Clinical features and outcomes of infective endocarditis in Egypt: an 11-year experience at a tertiary care facility

BACKGROUND

Few data are available on the characteristics of infective endocarditis (IE) cases in Egypt. The aim of this work is to describe the characteristics and outcomes of IE patients and evaluate the temporal changes in IE diagnostic and therapeutic aspects over 11 years.

RESULTS

The IE registry included 398 patients referred to the Endocarditis Unit of a tertiary care facility with the diagnosis of possible or definite IE. Patients were recruited over two periods; period 1 (n = 237, 59.5%) from February 2005 to December 2011 and period 2 (n = 161, 40.5%) from January 2012 to September 2016. An electronic database was constructed to include information on patients' clinical and microbiological characteristics as well as complications and mortality. The median age was 30 years and rheumatic valvular heart disease was the commonest underlying cardiac disease (34.7%). Healthcare-associated IE affected 185 patients (46.5%) and 275 patients (69.1%) had negative blood cultures. The most common complications were heart failure (n = 148, 37.2%), peripheral embolization (n = 133, 33.4%), and severe sepsis (n = 100, 25.1%). In-hospital mortality occurred in 108 patients (27.1%). Period 2 was characterized by a higher prevalence of injection drug use-associated IE (15.5% vs. 7.2%, p = 0.008), a higher staphylococcal IE (50.0% vs. 35.7%, p = 0.038), lower complications (31.1% vs. 45.1%, p = 0.005), and a lower in-hospital mortality (19.9% vs. 32.1%, p = 0.007).

CONCLUSION

This Egyptian registry showed high rates of culture-negative IE, complications, and in-hospital mortality in a largely young population of patients. Improvements were noted in the rates of complications and mortality in the second half of the reporting period.

[Invasive aspergillosis in the patient with oncohematologic disease]

Invasive aspergillosis is the most common invasive fungal infection in patients with acute hematological malignancies or treated with hematopoietic stem cell transplantation due to the marked alteration of the physiological mechanisms of antifungal immunity that takes place in these situations. For this reason, antifungal prophylaxis has a relevant role in these patients. The introduction of new antifungal agents has motivated the updating of recommendations for prophylaxis and treatment in different guidelines. The objectives of this chapter are a brief review of the mechanisms of immunity against fungi, the definition of risk for developing an invasive fungal infection and an update of the prophylaxis recommendations and treatment of invasive aspergillosis in the group of patients with hematological diseases.

Co-infection with bacterial and fungal endocarditis at scar tissue in an immunocompromised patient

We present the case of a 65-year-old immunocompromised male with a history of kidney transplantation, diabetes, coronary artery bypass, and cardiac resynchronization therapy device implantation who was finally diagnosed with an unusual form of infective endocarditis due to co-infection of fungal and bacterial pathogens. He was afebrile at the time of admission and presented with decompensated heart failure and pneumonia. A spleen abscess was discovered incidentally and prompted us to search for a cardiac source of emboli. Culture of the suppurative fluid drained percutaneously from the abscess was positive for Enterococcus and Aspergillus species. Transthoracic and transesophageal echocardiography revealed a mobile vegetation attached to the scarred myocardium of anterior septum - an unusual location for intracardiac vegetations. With regard to the prohibitive risk for redo surgery, the patient was managed medically with broad spectrum antimicrobial therapy. Finally, the patient died with severe sepsis. <Learning objective: Immunocompromised patients are at risk of opportunistic infections such as fungal endocarditis. Co-infection of fungal and bacterial pathogens is very rare. Early diagnosis of such infections needs a high level of clinical suspicion due to its non-specific presentations and culture negative essence. Many patients are afebrile during the disease course. Fungal endocarditis is characterized by large vegetations highly prone to systemic embolization even in the early stages of infection. Mortality is high despite optimal antimicrobial and timely surgery.>.

Correction: Aspergillus endocarditis: Diagnostic criteria and predictors of outcome, A retrospective cohort study

[This corrects the article DOI: 10.1371/journal.pone.0201459.].