Arjun C. Khadilkar, MD @akhadilkarMD @USFHealthMed @USFIMres #PVEC #Cardiology #Research Cardiac Imaging and Manageme...

Arjun C. Khadilkar, MD from the University of South Florida Morsani College of Medicine speaks about Cardiac Imaging and Management of Prosthetic Valve Candida Parapsilosis Endocarditis.

Link to Article:
https://www.cureus.com/articles/59959-cardiac-imaging-and-management-of-prosthetic-valve-candida-parapsilosis-endocarditis

Summary:

Fungal infective endocarditis is an uncommon and dangerous kind of endocarditis that can cause significant morbidity and death. Patients with implanted prosthetic valves, implantable cardiac devices, and intravenous drug usage have the highest risk of infection. We describe the case of a 45-year-old man who was diagnosed with Candida parapsilosis endocarditis after having a previous bioprosthetic mitral valve. Splenic infarcts were seen on computed tomography imaging of the abdomen, and transesophageal echocardiography revealed a 1.23 cm x 0.55 cm lesion on the bioprosthetic valve and a 1.02 cm x 0.545 cm lesion on the bioprosthetic valve. The patient was then given Amphotericin B and Fluconazole for the rest of his life. The imaging results and therapy of an uncommon disease process are highlighted in this instance.


Overview:

Fungal infective endocarditis (IE) is an uncommon and dangerous type of infective endocarditis (IE), with death rates as high as 50% [1]. Prosthetic valve implantation, cardiac implantation devices, and intravenous drug usage are all common risk factors [1]. Candida and Aspergillus species are the most frequent causative agents of fungal IE in general [1]. Candida parapsilosis (n = 8, 67 percent ), Candida glabrata (n = 3, 25 percent ), and Candida albicans (n = 1, 8 percent ) were determined to be the most frequent species in a six-year case analysis of 12 distinct instances of Candida IE [2]. Treatment of Candida IE with Amphotericin B with or without Flucytosine or high-dose echinocandin therapy, followed by life-long maintenance therapy with an oral azole, is recommended by the Infectious Diseases Society of America Candidiasis and the American Heart Association Endocarditis guidelines [2]. Treatment failure with medical care alone is frequent, however, since Candida species have evolved survival tactics that include the development of biofilms on native and artificial heart valves, which can result in low antifungal efficacy [1]. As a result, it's critical to include a surgical option in the treatment of native valve endocarditis, especially in patients with prosthetic valves, because early intervention has been shown to be advantageous [1]. Despite medicinal and surgical therapy, the general prognosis for fungal IE is poor, and active risk factor control is essential.

We present a case of a 45-year-old man with Candida parapsilosis IE in the setting of a bioprosthetic mitral valve, highlighting the computed tomography (CT) abdomen and pelvis, transthoracic echocardiography (TTE), and transesophageal echocardiography (TEE) image findings associated with this deadly disease.



Presentation of a Case:

A 45-year-old man arrived with four months of increasing abdominal distention. He had a history of intravenous drug use, liver cirrhosis related to hepatitis C, recent mitral valve endocarditis with a bioprosthetic mitral valve in 2019, gastroesophageal reflux disease (GERD), and pancytopenia. During the coronavirus-19 epidemic, the patient lost his insurance and stopped receiving normal healthcare. His abdomen distention resulted in a 40-pound unintended weight reduction due to decreased hunger and early satiety. The patient claimed that his GERD symptoms were well-controlled with daily pantoprazole and denied any concomitant symptoms of nausea, vomiting, or diarrhea. Prior to admission, the patient had been experiencing intermittent fevers for two weeks and shortness of breath for three days.

The patient was feverish with a temperature of 101°F, normotensive with a blood pressure of 116/77 mmHg, tachycardia with a heart rate of 114 beats per minute, and saturating 98 percent on room air at the time of admission.

Conversation:

Fungal prosthetic valve IE is an uncommon kind of IE that affects people all over the world. A previous literature analysis found 152 occurrences between 1995 and 2000, with intravenous injection drug usage being recognized as a risk factor in just 4.1% of cases [3]. Fungal IE is linked to high rates of severe morbidity and death, with total morbidity ranging from 67% to 37% and a six-month mortality risk of 37% [4,5]. There has been a scarcity of published studies and medical guidelines regarding the proper selection and duration of antifungal medication. Medical management with liposomal Amphotericin B (LAmB) 5 mg/kg/day (300 mg/day) and Flucytosine 150 mg/kg/day (9 g/day) as part of an initial treatment after positive blood cultures for Candida is the indicated intervention in those case reports that have been published [6]. The most recent Infectious Diseases Society of America (IDSA) guidelines from 2016 include recommendations for treating Candida infections in contaminated pacemakers, implanted cardiac defibrillators, ventricular assist devices, and native and prosthetic valve IE [7]. High-dose echinocandin therapy (Caspofungin 150 mg daily, Micafungin 150 mg daily, or Anidulafungin 200 mg daily) or high-dose echinocandin therapy (Caspofungin 150 mg daily, Micafungin 150 mg daily, or Anidulafungin 200 mg daily) are recommended in these guidelines [7]. In addition, for patients who are unable to undergo valve replacement, chronic long-term suppression with Fluconazole 400-800 mg daily is strongly recommended [7]. Our patient continues to see cardiology as an outpatient. In March 2021, echocardiography revealed decreased visibility of the bioprosthetic valve vegetation and a steady mitral valve peak velocity of 2.06 m/s.

Recent clinical investigations have added to our understanding of Candida IE. Rivosky et al. followed 46 patients with prosthetic valve IE for a median of nine months who were treated with LAmB vs echinocandin-based induction treatment. When compared to patients who got just echinocandins, patients who received only LAmB had a higher six-month survival rate (adjusted odds ratio: 13.52, 95 percent confidence interval 1.03-838.10) [4]. In addition, 21 patients were given long-term Fluconazole maintenance treatment for an average of 13 months, with minimal side effects [4]. Furthermore, as compared to the group treated with medical treatment, the 19 patients who received a cardiac surgical operation did not have improved survival outcomes over a six-month period [4]. The Infectious Diseases Society of America and the European Society of Clinical Microbiology and Infectious Diseases recommendations, which advocate early surgical intervention for all patients with prosthetic IE [5,8], are in conflict with these findings. Despite the limited sample size and low statistical power, this study offers insight into medicinal care as an alternative to surgical surgery.

Outcomes:

Candida IE is an uncommon pathogenic condition that has a high proclivity for infecting and compromising implanted prosthetic valves and cardiac devices. People who have used drugs in the past are at the highest risk among the general population. The patient in our instance had previously had bioprosthetic mitral valve replacement and was discovered to have recurrent IE on his bioprosthetic mitral valve. The patient was ultimately ruled out for surgery and was treated with Amphotericin B and long-term Fluconazole. The presentation of Candida parapsilosis IE and subsequent imaging results of this uncommon illness are the subject of this report. This example also emphasizes the necessity of reading current clinical standards and delivering proper medical care.