International Journal of Cardiology 118 (2007) e58 – e59 www.elsevier.com/locate/ijcard
Letters to the Editor
Candida parapsilosis endocarditis 8 months after transient candidemia Mutahir U. Khan a , Shaukat Ali a , Muhammad A. Baig a , Muhammad A. Rafiq a , Balendu C. Vasavada a , Ijaz A. Khan b,⁎ b
a Division of Cardiology, Long Island College Hospital Brooklyn, New York, USA Division of Cardiology, University of Maryland School of Medicine, 22 South Greene Street, S3B06, Baltimore, Maryland 21201, USA
Received 15 November 2006; accepted 31 December 2006 Available online 28 March 2007
Abstract We report a case of aortic valve endocarditis with aortic root abscess from Candida parapsilosis occurring 8 months after transient candidemia. Despite the fact that the patient was treated appropriately, candidemia persisted and later on presented with an embolic stroke as a complication of fungal endocarditis. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Candida parapsilosis; Fungal endocarditis; Native valve endocarditis; Aortic valve; Embolic stroke
Endocarditis is one of the most serious manifestations of the candidiasis. Certain species of Candida are very slow growing, and if not completely eradicated can present remotely with grave infective consequences. We report a patient with acute cerebrovascular accident secondary to infected emboli from aortic valve endocarditis resulting from slow growing Candida parapsilosis. A 59-year-old man developed sudden weakness of the right side of his body. In the emergency room he was found drowsy with expressive aphasia, left gaze preference, right facial droop, and right-sided hemiparesis. Prior history included right hemicolectomy for infective colitis 8 months earlier. The operation was complicated by enterocutaneous fistula, which was treated by the diverting colostomy and hyperalimentation with total parenteral nutrition given via peripherally inserted central venous catheter. After 8 weeks of treatment the patient developed fever. The blood cultures grew C. parapsilosis, which was treated with removal of peripherally inserted central venous catheter and oral fluconazole for 2 weeks. During current hospitalization the initial computerized tomographic scan of the brain was normal but a repeat scan in 24 h revealed acute infarct in the distribution of left middle ⁎ Corresponding author. Tel.: +1 410 328 2251; fax: +1 410 328 8225. E-mail address:
[email protected] (I.A. Khan). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.12.067
cerebral artery. The blood cultures drawn on the second day of admission grew non-Candida yeast. Intravenous amphotericin was started. On the third day of admission, the patient was found to be in heart failure with grade IV/VI diastolic murmur at aortic valve area. Echocardiogram showed mobile echo densities at the aortic valve with moderate aortic insufficiency. Patient underwent emergent cardiac surgery for aortic valve replacement and was found to have vegetations on all three aortic valve leaflets and aortic root abscess with extension to the left atrial roof. Patient received aortic valve and root replacement with reconstruction of left atrial roof. Culture of surgical specimen grew C. parapsilosis. Post operatively, the patient was treated with intravenous amphotericin for 2 weeks followed by oral fluconazole and had an uneventful recovery with minimal right-sided weakness. Prolonged intravenous hyperalimentation, antibiotic therapy, narcotic addiction, intravascular devices, and reconstructive cardiovascular surgery are the predisposing factors for fungal endocarditis [1,2]. C. parapsilosis once considered to be common with intravenous drug abuse is now an important nosocomial pathogen for infective endocarditis [2,3]. It has been frequently isolated form subungal space of the healthy volunteers and as well from stool of the subjects with malnutrition [4,5]. C. parapsilosis has growth preference in certain hyperalimentation
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solutions and sticks more to acrylic in a 50-mM glucose solution as compared to Candida albicans [6]. Nonalbicans Candida endocarditis has usually long duration of illness. In one review of isolated tricuspid valve endocarditis in non-drug addict patients it was found to be of 9month duration on average [7]. C. parapsilosis particularly is a slow growing infection and it has been reported to recur as late as 43 months after a positive blood culture [8–10]. Therefore, in order to avoid grave consequences, prolonged treatment of C. parapsilosis fungemia should be continued with multiple surveillance cultures until sterility is documented. References [1] Brandstetter RD, Brause BD. Candida parapsilosis endocarditis. Recovery of the causative organism from an addict's own syringes. JAMA 1980;243:1073. [2] Rubinstein E, Noriega ER, Simberkoff MS, Holzman R, Rahall JJ. Fungal endocarditis: analysis of 24 cases and review of the literature. Medicine (Baltimore) 1975;54:331–4.
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[3] Weems JJ. Candida parapsilosis: epidemiology, pathogenicity, clinical manifestations, and antimicrobial susceptibility. Clin Infect Dis 1992;14:756–66. [4] McGinley KJ, Larson EL, Leyden JJ. Composition and density of microflora in the subungal space of hand. J Clin Microbiol 1988;26:950–3. [5] Gracey M, Stone DE, Suharjono, Sunoto. Isolation of Candida species from the gastrointestinal tract in malnourished children. Am J Clin Nutr 1974;27:345–9. [6] Critchley IA, Douglas LJ. Differential adhesion of pathogenic Candida species to epithelial and inert surfaces. FEMS Microbiol Lett 1985;28:199–203. [7] Nandakumar R, Raju G. Isolated tricuspid valve endocarditis in nonaddicted patients: a diagnostic challenge. Am J Med Sci 1997; 314:207–12. [8] Tonomo K, Tsujino T, Fujioko Y. Candida parapsilosis endocarditis that emerged 2 years after abdominal surgery. Heart Vessels 2004;19: 149–52. [9] Galgiani J, Stevens D. Fungal endocarditis: need for guidelines in evaluating therapy. J Thorac Cardiovasc Surg 1977;73:293–6. [10] Samelson LE, Lerner SA, Resnekov L. Relapse of Candida parapsilosis endocarditis after long-term suppression with flucytosine: retreatment with valve replacement and ketoconazole. Ann Intern Med 1980;93:838–9.
