Clinical features, diagnosis and treatment outcome of fungal endocarditis: A systematic review of reported cases

Abstract

The landscape of fungal endocarditis (FE) has constantly been evolving in the last few decades. Despite the advancement in diagnostic methods and the introduction of newer antifungals, mortality remains high in FE. This systematic review aimed to evaluate the epidemiology, clinical features, diagnostic and therapeutic interventions in patients with FE. We also aim to examine the aforementioned factors as a determinant of mortality in FE. A literature search was performed in PubMed, Google Scholar and Scopus, and all patients ≥18 years with proven fungal endocarditis were included. A total of 220 articles (250 patients) were included in the final analysis. Candida was the commonest aetiology (49.6%), followed by Aspergillus (30%) and Scedosporium species (3.2%). The proportion of prosthetic valve endocarditis (PVE) and intravenous drug users was 35.2% and 16%, respectively. The overall mortality rate was 40%. On multivariate analysis, Aspergillus endocarditis (HR 3.7, 95% CI 1.4‐9.7; p = .009) and immunocompromised state (HR 2.8, 95% CI 1.24‐6.3; p = .013) were independently associated with mortality. Patients treated with surgery along antifungals had better survival (HR 0.20, 95% CI 0.09‐0.42; p < .001) compared to those treated with antifungals alone. Recurrence of FE was reported in 10.4% of patients. In conclusion, FE carries significant mortality, particularly in immunodeficient and Aspergillus endocarditis. We advocate the use of surgery combined with antifungals to improve clinical outcomes.

Aspergillus tubingensis Endocarditis: A Case Report and Review of the Literature

“…Aspergillus endocarditis is a rare event and represents the second cause of fungal endocarditis after Candida spp. [ 37 , 38 ]. Prosthetic heart valves, structural heart disease or past history of endocarditis were the most frequent underlying conditions [ 37 , 38 ].…”

“…[ 37 , 38 ]. Prosthetic heart valves, structural heart disease or past history of endocarditis were the most frequent underlying conditions [ 37 , 38 ]. History of active intravenous drug abuse has also been reported [ 37 , 39 ], although it is unclear whether the fungus originates from the drug or its adjuvant, or from the contaminated material of injection.…”

Fungal Infective Endocarditis Post Device Occlusion in Perimembranous Ventricular Septal Defect

“…9 Device associated endocarditis is not routinely reported in children after atrial and ventricular septal defect closure. 10,11 The device might get infected by carrying microorganisms either during the procedure or after the procedure. 7 It takes around 6 months for endothelialization to complete after device closure.…”

“…12 Medical treatment of fungal IE is usually not successful except in the neonates with mural endocarditis. 11 For majority of patients diagnosed with fungal IE, surgery along with antifungal medicines is needed. Consulting cardiology, infectious disease, and cardiac P Pe er ri im me em mb br ra an no ou us s V Ve en nt tr ri ic cu ul la ar r S Se ep pt ta al l D De ef fe ec ct t Pak Armed Forces Med J 2022; 72 (Suppl-3): S630 surgery departments early on is suggested in these cases.…”

“…Although the Imidazoles (e.g., Fluconazole) are not proven to be effective in human fungal IE, long -term therapy with these agents is recommended for patients who are unable to undergo surgery and are having infections caused by these microorganisms. 11,13 Cardiac surgery is required urgently at times and is imperative in patients with IE, but decision to perform surgical intervention is taken considering patient's clinical condition and taking into account several other parameters. There are no special guidelines for surgical management of pediatric IE, they are mostly an extrapolation of recommendations for managing IE in adults.…”