Candida Prosthetic Valve Endocarditis: Prospective Study of Six Cases and Review of the Literature
M. Hong Nguyen
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Minh Ly Nguyen
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Victor L. Vu
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Deborah McMahon
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Thomas F. Keys
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Morteza Amidi
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Clinical Infectious Diseases 1996;22:262-7 1996 by The University of Chicago.
All rights reserved. 1058--4838/96/2202-0010$02.00
1
Received 10 May 1995; revised 18 September 1995. Division of Infectious Diseases
,
501 Kaufmann, Pittsburgh, Pennsylvania 15213
2
From the Veterans Affairs Medical Center and University ofPittsburgh
,
Pittsburgh, Pennsylvania
Candida prosthetic valve endocarditis (PVE) is a rare entity; however, its incidence is expected to increase given the recent increase in incidence of nosocomial bloodstream candida infection. This report reviews six cases of candida PVE studied prospectively plus 12 cases previously reported in the literature. Transesophageal echocardiography was more sensitive than transthoracic echocardiography in detecting vegetations. Valvular replacement combined with antifungal therapy has been the standard treatment. However, successful therapy with long-term administration of oral fluconazole has been reported for five patients. The mortality due to candida PVE was high, especially when PVE was complicated by congestive heart failure and persistent fungemia. For uncomplicated PVE, the mortality rate for patients receiving antifungal therapy alone (40%) was no worse than for those receiving combined medical and surgical therapy (33%).
Methods
We evaluated six cases of candida PVE encountered in a
prospective, multicenter study of PVE [1] and a prospective,
multicenter study of candidemia [3]. Both multicenter studies
used identical objective criteria for clinical manifestations of
bloodstream infection and severity of illness.
A 61-year-old man underwent coronary artery bypass and
mechanical aortic valve replacement. One month postopera
tively, low grade fever and night sweats occurred daily. Despite
therapy with antibacterial agents, these symptoms persisted and
a 15-lb weight loss occurred. The patient was admitted 2
months after the operation. His oral temperature was 100.1 OF.
Two subconjunctival petechiae and a small erythematous lesion
of the right third fingertip were noted. A 2/6 holosystolic mur
mur radiating to the neck was heard. The WBC count was
7,000/mm3 and the hematocrit was 29%. An electrocardiogram
was unrevealing. Four of six blood cultures yielded C. albicans.
Therapy with amphotericin B (0.5 mg!kg, or 50 mg) and flucy
tosine was initiated. Serial transthoracic echocardiograms did
not show any valvular dysfunction or vegetations; transesopha
geal echocardiography was not performed routinely for endo
carditis in 1989. CTs of the head and abdomen were normal.
He was treated for 6 weeks with amphotericin B (total dose,
1,935 mg) and flucytosine. The patient's fever recurred 2 weeks
after the antifungal agents were discontinued; blood cultures
again yielded C. albicans. Therapy with amphotericin Band
flucytosine was restarted. One week later, a new splenic infarct
was visualized on a CT of the abdomen. Splenectomy was
performed; Grocott-Gomori methanamine-silver nitrate stain
ing revealed budding yeasts in the splenic blood vessels but
not in the parenchyma. The cardiothoracic surgical consultant
believed that the risk of death posed by valve replacement
would be substantial. Amphotericin B (total dose, 1,870 mg)
and flucytosine were administered for another 6 weeks. Fluco
nazole was then given for 4.5 years (the first year at a dosage
of 400 mg daily and the next 3.5 years at a dosage of 200 mg
daily). The patient was alive and weIll year after discontinua
tion of therapy.
Results
We analyzed 18 patients, including 6 who were enrolled in
two national prospective studies conducted by us (table 1) and
12 reported in the English-language literature since 1985.
Demographics. There were 11 males and 7 females, with
a mean age of 53 years. Seven patients were older than 60 years
of age. The major underlying diseases necessitating valvular
replacement were atherosclerotic heart disease (28%; 5/18),
rheumatic heart disease (22%; 4/18), valvular dysfunction of
unclear etiology (33%; 6/18), congenital heart disease (5%;
1118), ascending aortic dissection (5%; 1/18) and candida na
tive valve endocarditis (5%; 1118). Fifty percent of patients
(9/18) underwent cardiothoracic surgery within 60 days prior
to the onset of candida endocarditis; 44% (7/16) had indwelling
vascular catheters in place; and 38% (6/16) had received broad
spectrum antibacterial agents. None of the patients were intra
venous drug users.
Clinical manifestations (table 2). Sixty-seven percent of
the cases (12/18) presented with abrupt onset of symptoms,
and 33% (6/18) had a more insidious and progressive course.
Characterization of endocarditis. All 18 patients had mul
tiple positive blood cultures for Candida species, with a median
of 5 and a mean of 7 positive blood cultures (range, 1-15).
C. albicans was the causative agent in 9 patients, Candida
parapsilo (...truncated)