Prosthetic valve endocarditis due to Candida parapsilosis – a rare case report

Abstract

Fungal endocarditis is a rare and fatal condition, most frequently caused by species of the genera Candida and Aspergillus. Fever and changing heart murmur are the most common clinical manifestations. The diagnosis of fungal endocarditis is challenging, with prosthetic valve endocarditis being extremely difficult to diagnose. The optimal management of the condition still remains debatable. We present a case of prosthetic valve endocarditis caused by Candida parapsilosis, managed empirically with liposomal amphotericin B, which was later shifted to combination therapy with high-dose echinocandin and fluconazole, but had a fatal outcome because the patient could not undergo timely surgical intervention. Treating C. parapsilosis endocarditis cases is difficult because of their biofilm production on native and prosthetic heart valves. A combined approach consisting of a high index of clinical suspicion, early diagnosis using serological markers followed by culture or PCR and prompt initiation of appropriate antifungals may aid in improving outcomes.

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

“…In 86 reports, 91 cases of definitive fungal IE were described. These reports involved fifteen cases with Candida parapsilosis [40][41][42][43][44][45][46][47][48][49][50][51][52][53][54] , seven cases with C. albicans [55][56][57][58][59][60][61] , three cases with C. tropicalis [62][63][64] , eight other species with Candida [65][66][67][68][69][70][71][72] , eight cases with Candida with a bacterium [73][74][75][76][77][78][79][80] , ten cases with Aspergillus fumigatus [81][82][83][84][85][86][87][88][89]…”

“…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] .…”

“…Other advanced diagnostic techniques include the detection of 1,3-β-D-glucan and mannan for Candida [41,43,48,51,83,92,106] or for Aspergillus [84,85,89,95,96,102] and other fungi [52,107,118,121,123] , but these methods are timeconsuming [107] and are not always easily available [48] . Clearance of these antigens by neutrophil WBC can explain false negative results [89,95] .…”

“…However, even repeated TEE can remain negative for some time [61] . Some echocardiographic features point to fungal IE, such as large vegetations [48,57,64,68,78,84,99] , obstruction of a valve prosthesis [42,51,73,105,123] , presence of fungal balls [76,91] , and mural, intracardiac and other non-valvular manifestations [79,81,82,85,99,112,113,114,120,122] . TEE increases the diagnosis in TTE-negative patients, but this invasive procedure carries the risk of embolization [38] .…”

Candida endocarditis: Update on management considerations

“…Different Candida species can lead to advanced clinical infections, yet the most common agent leading to CE remains CA despite distinct patient characteristics and underlying risk factors[ 18 ]. Moreover, Candida parapsilosis was linked to infected medical devices such as prosthetic valves and transmitted through direct contact[ 19 - 21 ]. Candida dubliniensis and Candida glabrata are predominantly found among human immunodeficiency virus/acquired immunodeficiency syndrome patients with oral thrush and patients who are immunosuppressed on broad-spectrum antibiotics, respectively[ 18 , 22 ].…”