Surgical treatment of native valve Aspergillus endocarditis and fungemic vascular complications

Abstract

Systemic infection with Aspergillus is an opportunistic disease that affects mainly immunocompromised hosts, and is associated with a high mortality rate. It typically occurs in patients with several predisposing factors, but Aspergillus endocarditis of native valves is rare and experience in diagnosis and treatment is limited. We report a case of native valve endocarditis caused by Aspergillus. A 35-yr-old male patient who underwent pericardiocentesis four months previously for pericardial effusion of unknown etiology presented with right leg pain and absence of the right femoral artery pulse. Cardiac echocardiography revealed severe mitral insufficiency with large mobile vegetations, and computed tomographic angiography showed embolic occlusion of both common iliac arteries. We performed mitral valve replacement and thromboembolectomy, and Aspergillus was identified as the vegetation. We started intravenous amphotericin B and oral itraconazole, but systemic complications developed including superior mesenteric artery aneurysm and gastrointestinal bleeding. After aggressive management, the patient was discharged 78 days post surgery on oral itraconazole. He was well at 12 months post discharge but died in a traffic accident 13 months after discharge.

Keywords: Aspergillus; Endocarditis; Surgery; Vascular Diseases.

Fig. 1

(A) Preoperative cardiac 2-D echocardiography. This shows large mobile vegetations of the anterior leaflet of the mitral valve. The estimated size of vegetation was 1.2×1 cm. (B) Preoperative computed tomographic angiography shows focal occlusion of the iliac bifurcation and the right femoral artery. (C, D) Histological findings of vegetation of the mitral valve (C, H&E stain ×400; D, GMS stain ×400). Note the septate hyphae consistent with Aspergillus.

Fig. 2

3-D reconstruction of the computed tomographic angiography at 40 days after the first operation. This shows multiple aneurysmal of the aorta, such as the superior mesenteric artery, splenic artery, left iliac artery.