Candida tropicalis Endocarditis
A 73-year-old man presented with weakness, weight loss, fever, and disorientation of 3 weeks’ duration.
Three months earlier, a transurethral prostatectomy had been performed elsewhere. After surgery, the patient developed urosepsis caused by Escherichia coli that was treated with amoxicillin and gentamicin. Also, a Candida species had grown in urine and 1 blood culture. However, no treatment was started against Candida, and species determination was not performed.
When the patient was admitted to our hospital, some splinter hemorrhages and conjunctival petechiae were found. The blood pressure was 115/60 mm Hg, and the pulse was strong and regular at 80 bpm. A holosystolic cardiac murmur was heard over the precordium, with a diastolic component compatible with aortic regurgitation. Transthoracic echocardiography showed a large, oscillating vegetation on the aortic valve(Figures 1⇓ and 2⇓, large arrow; Ao indicates aorta ascendens) and an abscess in the aortic root (Figure 2⇓, small arrows). Blood cultures were positive after 1 day for a Candida species that subsequently was shown to be C tropicalis. Treatment had already been started with amphotericin-B 0.6 mg · kg−1 · d−1 IV and flucytosine 25 mg/kg IV 4 times daily.
Awaiting valve replacement with a suitable homograft, the patient suddenly became severely hypotensive (systolic blood pressure <60 mm Hg) and lost consciousness. Reanimation attempts failed. Echocardiography performed during reanimation revealed that the vegetation had herniated through the aortic valve and completely obstructed the left ventricular outflow tract.
Postmortem examination confirmed the clinical diagnosis and showed that a herniated fungal vegetation completely obstructed flow to the ascending aorta (Figure 3⇓). Postmortem cultures of the aortic vegetation and abscess grew C tropicalis.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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