DiscussionÂ
Fungal endocarditis (FE) is an extremely rare cause of septic embolism,
especially in immunocompetent patients. AE is reported in 20–30% of
all FE cases, affecting nearly 0.1% of all prosthetic cardiac valves.
Congenital heart disease, prosthetic valves, malignancy, solid-organ
transplant, bone marrow transplant, and immunosuppression are the main
risk factors for FE.1
The diagnosis of FE is challenging because the clinical symptoms are
non-specific. In nearly 50% of cases, the diagnosis is postmortem.
Blood cultures are often negative, even in disseminated infection. Some
non-culture-based diagnostic methods, such as galactomannan enzyme
immunoassay, are approved by the United States Food and Drug
Administration (FDA). However, histological confirmation remains the
gold standard for diagnosis.2
The clinical presentation of AE is vague, with fever and cardiac murmurs
being the most common features, followed by embolization-related
symptoms and cardiac failure. Clinically significant coronary embolism
(CE) has been reported in 1.5% of cases with infective endocarditis,
micro-emboli to the coronary arteries were present in more than 60% of
cases on postmortem examination, particularly in mitral valve IE,
vegetation larger than 10mm, and fungal endocarditis.3CE is considered definite in the following scenarios: angiographic
evidence of CE and thrombosis without arteriosclerotic lesions, CE in
several locations simultaneously, or the presence of concomitant
systemic embolization not attributable to an apical
thrombus.4
In this case, we performed a balloon angioplasty with aspiration
thrombectomy which is the preferred treatment in STEMI secondary to
septic embolism. Experience with thrombolytic therapy has been
unfavorable and associated with a high risk of complications and low
efficacy. Cardiac complications of septic coronary embolization during
percutaneous transluminal coronary angioplasty are mycotic septic
aneurysm, perforation, carditis, and resistant
vegetations.4 We empirically initiated Vancomycin.
Nevertheless, Voriconazole is the antifungal therapy of choice; some
experts recommend the addition of an echinocandin or amphotericin
B.5