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A rare case of bioprosthetic mitral valve endocarditis due to Candida parapsilopsis: A Case Report and Literature Review

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A rare case of bioprosthetic mitral valve endocarditis due to Candida
parasilopsis: A Case Report and Literature Review
Clauden Louis, MD , Juan A. Siordia, Jr., MD, Sunil M. Prasad, MD.
University of Rochester Medical Center, Rochester, NY, USA.
We present a 34-year-old married Caucasian female with 20 pack
year cigarette smoking history, illicit drug use with cocaine
endorsing a history of previous intravenous drug use who
experienced significant shortness of breath four months’ statuspost
bioprosthetic mitral valve replacement four months prior.
The patient history was significant for thalassemia, hyperthyroidism
and severe mitral regurgitation and stenosis status post mitral valve
replacement with a tissue valve four months prior now presenting
to the emergency room with 4-day history of low-grade fever, night
sweats, coughing, 15-pound unintentional weight loss and
worsening shortness of breath. A transthoracic echocardiogram
showed increased echogenicity of the mitral valve leaflet with
moderate mitral stenosis, moderate pulmonary artery pressures
and concern for mitral vegetation.
Relevant History
Patient Demographics
Pre-Operative Plan
Results
Conclusion
The patient went for surgery on cardiopulmonary bypass. The atrial
septum was divided and the valve was found to be grossly infected.
After removal, the mitral annulus was inspected for residual disease
and thoroughly washed. A 25 mm Edwards Magna Ease mitral valve
was placed and secured with Cor-knot. The septum and atrium were
closed appropriately. The heart regained normal sinus rhythm
however was noted to have intermittent bouts of complete heart
block. Pacing wires were placed and the patient taken to the ICU in
critical condition. The patient extubated same evening, and was
subsequently discharged with antifungal therapeutics on postoperative
day 4 with her hospital stay otherwise uneventful.
Chest X-Ray before (left) and after (right) surgery and antifungals
Moderate pulmonary edema trace effusions. (left). Trace pulmonary edema (right)
Transthoracic Echocardiogram before (left) and after (right) surgery and antifungals
Bioprosthetic mitral valve replacement with vegetation concerning for endocarditis, but no abscess or significant
regurgitation (LEFT). Versus Mildly reduced LVEF with apical wall motion abnormalities. Grossly normally functioning
mitral valve prosthesis (see text). Mildly dilated and hypokinetic right heart with borderline elevated pulmonary artery
systolic pressure. No vegetations seen. (RIGHT)
Figure 3 – Wall Motion
Diffusely normal
Prosthetic valve endocarditis is a serious complication that can
occur after intervention. The gravity of prosthetic valve endocarditis
subjugates it toward surgical treatment. (Nishimura) Fungal
prosthetic valve endocarditis requires immediate attention. Hospital
survival rates are recorded at 20-45% and long-term survival is also
unfavorable due to the incurable rate of the pathogen. (Miller,
Muehrcke) Other adjuvant therapies that prolong survival include
pre-operative amphotericin B treatment, early diagnosis, use of
homograft tissue, and postoperative antifungal therapy. (Muehrcke)
About 67% of patients with fungal prosthetic valve endocarditis also
presented with paraprosthetic abscesses. (Miller, Muehrcke)
Lifelong antifungal therapy may contribute a significant factor in
long-term survival.
The patient underwent multidisciplinary assessment in
preoperative rounds and was considered a candidate for mitral
valve surgery, however deemed high-risk given her pulmonary
hypertension and recent cardiac surgery. An imaging computed
tomography of the chest, abdomen and pelvis was performed to
check for gross abscess of which none presented. The patient
adamantly refused chronic warfarin use and was subsequently
planned for surgical intervention with tissue prosthetic valve in the
mitral position due to moderately restricted diastolic leaflet motion
and vegetation on the anterior leaflet. Due to fungemia,
caspofungin was indicated however mild hepatic enzyme elevations
prompted health care teams to titrate therapeutic doses prior to
transition to oral fluconazole. Subsequent to surgical intervention
Was there substance abuse discussion and plans, we need to
recognize that her disease is not endocarditis it is drug addiction
the symptom is endocarditis
Discussion
[1] Miller DG. Predictions of outcome in patients with prosthetic
valve endocarditis (PVE) and potential advantages of homograft
aortic root replacement for prosthetic ascending aortic valve graft
infection. J Card Surg. 1990;5:53-62.
[2] Muehrcke DD, Lytle BW, Cosgrove DM. Surgical and long-term
antifungal therapy for fungal prosthetic valve endocarditis. Ann
Thorac Surg. 1995;60:538-43.
[3] Nishimura RA, Otto M, Bonow RO, Carabello BA, Erwin JP,
Guyton RA, et al. 2014 AHA/ACC guidelines for the management of
patients with valvular heart disease: a report of the American
College of Cardiology/American Heart Association Task Force on
Practice Guidelines. J Am Coll Cardiol. 2014;63:e57-185.
References

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