Aspergillus Vegetative Endocarditis Complicated with Schizocytic Hemolytic Anemia in a Patient with Acute Lymphocytic Leukemia

Abstract

Aspergillus vegetative endocarditis developing in a patient with acute lymphocytic leukemia during the phase of hematological remission has led to a fatal outcome, complicated with severe hemolytic anemia with red cell fragmentation. Systemic aspergillosis may involve heart valves with underlying disorders, but seldom affects intact valves even in severely compromised hosts. Among such rare cases so far reported, only 2 cases have been documented in acute leukemia, despite a huge prevalence of pulmonary and systemic aspergillosis in hematological malignancies. Our present case is essentially the same as in the preceding two cases in that endocarditis occurred during the hematological remission. These clinical observations may suggest that every leukemic patient suffering from aspergillosis is susceptible to the valvular complication after, rather than during, the period of severe myelosuppression, because platelets play an important role in the formation of thrombotic lesions.

Hemolytic Anemia in Native Valve Infective Endocarditis

“…Hemolytic anemia has been reported in only a few previous. [2][3][4][5][6][7] Maeda et al reported a 65-year-old female with hemolysis associated with streptococcal endocarditis of the mitral valve. 2 That patient had an underlying obstructive hypertrophic cardiomyopathy with a 115-mmHg pressure gradient in the left ventricular outflow tract and a moderate mitral regurgitation due to mitral valve prolapse.…”

“…Nishiura et al described hemolytic anemia with Aspergillus endocarditis involving the mitral valve in a patient with acute lymphocytic leukemia. 3 Postmortem examination of their patient showed huge vegetations on the mitral valve, and they postulated that the rapid progression of vegetations resulted in a powerful turbulent flow that caused intravascular hemolysis. Naidoo et al also reported intravascular hemolysis with fragmented erythrocytes in a patient with isolated enndocarditis of the pulmonary valve.…”

“…Physical examination revealed a grade IV/VI holosystolic murmur at the left lower sternal border, a grade III/VI diastolic blowing murmur at the pulmonic area and hepatosplenomegaly with palpable systolic pulsation of the liver. The hemoglobin was 5.8 g/dl and reticulocytes 153‰; lactate dehydrogenase was 543 U/L (normal: 47-140) and haptoglobin less than 24.3 mg/dl (normal, 53-170); the platelet count was 23×10 3 /mm 3 . A peripheral blood smear displayed numerous fragmented erythrocytes, spherocytes, giant platelets and polychromasia of red blood cells.…”

“…1 Hemolytic anemia associated with native valve infective endocarditis has been noted only in a few previous reports. [2][3][4][5][6][7] We describe an unusual case of endocarditis-induced hemolysis that resolved after removal of the vegetations, valvectomy and repair of a congenital defect.…”

Hemolytic anemia due to native valve subacute endocarditis with Actinomyces israelii infection

“…Both mechanical hemolysis and autoimmune hemolysis have been described 2, 3, 4. Hsuan‐Li et al reviewed six cases of hemolytic anemia secondary to endocarditis; in all the cases, there was the presence of fragmented erythrocytes suggestive of intravascular hemolysis 5.…”