Candida endocarditis treated with a combination of antifungal chemotherapy and aortic valve replacement.

Abstract

A case of Candida albicans endocarditis is described in which treatment with 5-fluorocytosine was started after aortic valve replacement, but relapse followed discontinuance of treatment. At a second operation the aortic valve was replaced under 5-fluorocytosine cover and treatment was continued with both 5-fluorocytosine and amphotericin-B. There was an initial improvement in signs of heart failure, but on I9 August the shortness of breath increased, and three days later fresh splinter haemorrhages were noted. In view of this, treatment was started with benzyl penicillin 8 mega units intravenously per day, though as yet no organism had been isolated from the cultures of blood or urine. The pyrexia settled, but after 5 days the patient began to suffer sweating attacks, and again his temperature rose. The antibiotic used was changed to cephaloridine 6 g daily, and within one week the patient became apyrexial.On ii September, at IO1.5 p.m., he suddenly developed gross left ventricular failure with a respiratory rate of 50 per minute, and a full length diastolic murmur. A diagnosis of ruptured aortic cusp was made, and emergency valve replacement was performed by Mr. J. E. C. Wright using a Series I200 Starr-Edwards prosthesis (No. ii). At operation the aortic valve was heavily calcified and there were large vegetations involving all three cusps, the non-coronary cusp being destroyed and incompetent. Antibiotic therapy during and shortly after the operation was with the current standard postoperative antibiotic regimen: intravenous gentamycin 40 mg t.d.s. and cloxacillin 500 mg q.d.s.The immediate postoperative course was uneventful, but on I8 September Candida albicans was isolated from blood cultures taken before operation on the ii and 14September. This was sensitive to 5-fluorocytosine at a minimum inhibitory concentration of 0.35 ,ug/ml. Culture of the valve itself grew the same organism, as did three midstream urine specimens taken during this period. One culture from the excised valve also grew actinobacter. Histology of the valve revealed subacute inflammation with lymphocytes and plasma cells, and Gram-positive budding yeasts were demonstrated. Serum contained no precipitins for Candida albicans on 14 September, and the agglutinin titre was less than I: 4. No murmurs were heard at this time.

Fungal endocarditis: patients at risk and their treatment

“…The most common FE pathogens are Candida spp., most commonly after cardiac surgery and complicating bacterial endocarditis therapy (Seelig et al, , 1974Engleman et al, 1973;Rubinstein et al, 1975;Stone, 1975;Turnier et al, 1975;Utley, Mills and Roe, 1975;Premsingh et al, 1976;Gladstone et al, 1976;Watanakunakorn, 1977;Rotheram and Magovern, 1977;Arnon and Ehrlich, 1977;Eilard et al, 1978;Wain et al, 1979). Fungal endocarditis is usually a valvular infection although mural infection occurs in severely immunosuppressed hosts (often with indwelling catheters) and in other patients with disseminated candidiasis.…”

Synergism of Polyene Antibiotics with 5-Fluorocytosine

“…Com bined treatment with reduced doses of amph. B and usual doses of 5-FC has shown to be an efficient and relatively safe therapy in man [8,14,34,35]. Other combinations of amph.…”

Screening for Candidosis in Patients with Open‐Heart Surgery: Vorsorgliche Suche nach Candidosen bei Patienten mit Operationen am offenen Herzen

“…C. parapsilosis, C. krusei, C. guillermondii, C. stellatoidea as well as C. tropicalis were also cultured (8,13,18,24). In most cases of endocarditis Amphotericin B (1, 6, 8, 14, 17, 25) and 5-fluorocytosin treatments (8,14,17,22) proved to be ineffective. Earlier inycotic serologic examinations were rarely performed in patients undergoing open-heart surgery.…”