Systemic aspergilloma post aortic root surgery following coronary artery stenting: diagnostic and management dilemma

Abstract

Aspergillus infections such as Aspergillus endocarditis were once relatively rare occurrences, however, due to the increased use of intracardiac devices, the incidence has grown. With mortality rates close to 100%, in medically treated cases, it is paramount that early diagnosis and treatment are performed. An immunocompetent aviculturist presented 8 months post aortic root replacement for severe aortic regurgitation with a composite graft, with central crushing chest pain. Investigations confirmed ST elevation inferior myocardial infarction due to stenosis of the origin of the right coronary artery, which was stented. Echocardiogram demonstrated a mobile mass posterior to the left ventricular outflow tract. Following referral to our cardiothoracic surgeons, a polypoidal mass covering the right ostial button was noted along with systemic complications of the disease. Emergency redo aortic valve replacement with a homograft and coronary artery bypass was performed. Histological analysis confirmed A. fumigatus and the patient was started on intravenous voriconazole.

Figure 1

Histological specimen of the patient's spleen following splenectomy, demonstrating an area of acute inflammation and necrosis with fungal hyphae (H&E stain, ×200).

Figure 2

Grocott stain of splenic tissue showing the Aspergillus-type fungal hyphae ( ×400).