Native Valve Aspergillus Endocarditis in a Non-Neutropenic Immunocompromised Patient on Anti-TNF α Blockers Therapy

Abstract

Invasive aspergillosis is a rare opportunistic infection mainly occurring in patients with a well-established risk such as neutropenia or conditions that lead to chronically impaired cellular immune responses. Systemic corticosteroids are a well-known risk factor for fungal infections. Recently, reports of invasive aspergillosis in patients treated with monoclonal biologic agents, such as tumor necrosis factor-alpha inhibitors, have been increasing. We present the case of a 47-year-old female patient with seronegative spondyloarthropathy treated with infliximab and corticosteroids. The patient presented classical symptoms of an acute lower respiratory infection, and she was treated with a β-lactam antibiotic. Infliximab administration was deferred until nine days after clinical recovery. Fourteen days after drug administration, she was admitted with a symptomatic subcortical hematoma in the left parietal region. There was a rapid neurological recovery, and there were no risk factors for haemorrhagic stroke detected. The chest X-ray revealed an oval mass with an air crescent sign, and the CT scan was suggestive of aspergilloma. Bronchoalveolar lavage cytology identified Aspergillus spp. Voriconazole was initiated and, after one month of treatment, the patient was readmitted with a left facial palsy associated with hemiparesis and dysarthria. Laboratory evaluation showed leukocytosis and elevated C-reactive protein. A severe right middle cerebral artery stroke was present on the brain CT scan. Transesophageal echocardiogram revealed large mitral valve vegetation, and the diagnosis of Aspergillus endocarditis with cerebral embolization was made. Fungal infections are challenging due to the diagnosis infrequency and paucisymptomatic natural history. Despite being crucial in the treatment of autoimmune diseases, immunosuppressive drugs increase the risk of fungal infection. It is extremely important to consider Aspergillus infection in immunosuppressed patients, and the need for prophylaxis in non-neutropenic patients with risk factors should be clarified.

Endocarditis caused by Aspergillus fumigatus in a patient 9 months after COVID-19 infection recovery: a case report and review of the literature

“…The sensitivity of blood culture for the detection of Aspergillus infection is low. However, negative results do not exclude the diagnosis [ 39 ]. The most recent Infectious Diseases Society of America (IDSA) guidelines recommend using a combination of all the mentioned diagnostic tests for the detection of invasive aspergillosis [ 40 ].…”

“Not much room for mushrooms” in the heart: knowns and unknowns of fungal infective endocarditis

“…In many cases with negative cultures or difficulties in identifying the infecting fungal microorganism, beta-D-glucan testing was performed. This was needed in a minority of Candida infections [51,54,55] but more often in Aspergillus [81,84,87,90,92,96] and certain other fungal species [101,106,107,118,[120][121][122][123][124] . Detection for the presence of galactomannan was also performed in IE by Aspergillus [85,89,92,93] and other uncommon species [112][113][114]120,121,125] .…”

“…This was needed in a minority of Candida infections [51,54,55] but more often in Aspergillus [81,84,87,90,92,96] and certain other fungal species [101,106,107,118,[120][121][122][123][124] . Detection for the presence of galactomannan was also performed in IE by Aspergillus [85,89,92,93] and other uncommon species [112][113][114]120,121,125] . Matrix-Assisted Laser Desorption Ionization Time-of-Flight Mass Spectrometry (MALDI-TOF MS) has been developed to sequence proteins, map biomolecules in tissues, identify microorganisms, and analyze several biochemical assays in a short time.…”

“…It was used in five patients with Candida infection [52,63,66,68,72] , and in 5 patients with other species [109,111,[113][114][115][116] , but not with Aspergillus. Quantitative polymerase chain reaction (qPCR) with genetic sequencing was performed in only one patient with Candida infection [71] , three with Aspergillus infection [81,92,95] , and for several other microorganisms [112,117,122,124,125] . To document and, if necessary, treat ocular involvement, an ophthalmic examination was performed in ten patients with Candida infection [45,49,52,56,57,59,62,63,76,78] , five patients with Aspergillus [81,87,88,93,97] , and three patients with other species [113,114,124] .…”

“…However, some immunocompetent patients could suffer from fungal IE [121] and risk factors may either be absent [99,101] or restricted to an indwelling urinary catheter [59,67] . Fourth, other clues can be IV drug use [40,55,57,61,66,73,74,92] , hemodialysis [16,94] , an earlier IE [56,61] , or extended treatment by antibiotics for other reasons [54,70,86,101] . Last, a high index of suspicion for fungal IE should be maintained in patients with sepsis, negative blood culture before any antibiotic treatment, and known risk factors who do not respond well to broad-spectrum antibiotics.…”