Fungal endocarditis of a bioprosthetic aortic valve. Pharmacological treatment of a Candida parapsilosis endocarditis.

INTRODUCTION: In October 2011, a 72-year-old man was referred from a peripheral hospital with subsequent diagnosis: fungal sepsis with suspicion for endocarditis of a bioprosthetic aortic heart valve. In May 2010, a bioprosthetic aortic valve implantation (Edwards Magna) and CABG (LIMA graft on LAD) were performed. CASE: At the time of admission, the patient was in good general condition; the physical examination was unremarkable. Hemoculture detected Streptococci thermophilus and Candida parapsilosis. Neither an oscillating intracardiac mass on the valve nor an abscess could be detected in several transesophageal echocardiographies (TEEs). The F(18)-FDG PET-CT showed an increased tracer uptake in the area of the prosthetic aortic valve. The findings argued for a fungal endocarditis of the prosthetic aortic valve. Heart surgeons refrained from implantation of a new prosthetic aortic valve because of the unfavorable prognosis. Therefore, high-dose i.v. therapy with liposomale amphotericin B (5 mg/kg BW) and voriconazol (4 mg/kg BW twice a day) was started. A new F(18)-FDG PET-CT after 2 weeks showed no tracer uptake in the area of the prosthetic aortic valve. The hemoculture was also negative. The patient recovered; CRP values were within normal limits. Life-long antifungal therapy with fluconazol (400 mg/day) was recommended.
CONCLUSION: There are no definitive treatment recommendations for fungal endocarditis. Surgical therapy is the first choice in prosthetic valve endocarditis, which however cannot be performed in all patients. In these cases high dose and life-long medical therapy is necessary to prevent re-infection of the valve, even if (transient) deterioration of renal and liver function occurs.