The tell-tale heart: Aspergillus fumigatus endocarditis in an immunocompetent patient

Rapid diagnosis of Aspergillus fumigatus endocarditis using mNGS assay: A case report and review of the literature

Fungal endocarditis is caused mainly by Candida albicans and Aspergillus spp. and was first reported in the 1950s. Natural-valve endocarditis caused by Aspergillus is relatively uncommon. In this case, a 56-year-old male patient was admitted to the hospital on account of a cough accompanied by chills and fever and ineffective self-medication. Infective endocarditis was initially suspected based on echocardiography (indicating right atrial growth) and clinical manifestations. However, routine pathogen detections were always negative. The patient's condition was identified as Aspergillus fumigatus endocarditis (AFE) and was treated with targeted therapy, considering the detection of significant AFE sequences in the blood through metagenomic next-generation sequencing (mNGS). On this basis, the paper further summarizes the clinical manifestations, diagnosis, treatments, and outcomes of AFE endocarditis cases reported in recent years, aiming to provide a reference to better understand this rare infective disease and guide medical practitioners in choosing the right diagnostic and therapeutic strategy.

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.

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.

Fungal mobile mass on echocardiogram: native mitral valve Aspergillus fumigatus endocarditis

The most common type of infective endocarditis is bacterial endocarditis. However, fungal infections have been seen more frequently, mostly in the immunocompromised population. We report a case of invasive Aspergillus fumigatus native mitral valve endocarditis. The patient received appropriate empiric antifungal treatment with a combination of liposomal amphotericin B and flucytosine, associated with surgical debridement, valve replacement and chordae tendineae repair. Despite receiving the standard treatment of Aspergillus endocarditis, and susceptibility of the microorganism to the antifungal regimen, the patient, unexpectedly, developed early-onset septic emboli. It is surprising to see that the patient had developed such complications early, despite attempts to eliminate the source of infection with surgical intervention.

Pulmonary endarterectomy for saddling pulmonary embolism by Aspergillus fungus in an immunocompetent patient

We present a case of tricuspid valve Aspergillus endocarditis with saddle shaped massive pulmonary embolism occurring in an immunocompetent host. The patient was managed uniquely by pulmonary endarterectomy (PEA) and combination antifungal chemotherapy with Liposomal amphotericin-B + caspofungin.