Fungal Endocarditis: A Successful Case with Medical Therapy Alone

• Author(s): Abreu, Jéssica ; Mateus, Daniela ; Leal, Ema ; Garrote, Ana Raquel ; Maltez, Fernando
• Date: 2024
• Origin: SPMI Case Reports
• Subject(s): Casos Clínicos
• Document Type: Journal article
• Language: Portuguese

Description

A endocardite fúngica é uma condição rara e potencialmente fatal, em geral causada pelas espécies Candida e Aspergillus. Incide maioritariamente em doentes imunossuprimidos, com história pregressa de endocardite, ou com próteses ou dispositivos intracardíacos. As terapêuticas antifúngicas e cirúrgicas são essenciais pelo intuito curativo e evicção de fenómenos embólicos. São raros os casos de sucesso tratados com terapêutica médica isolada. Apresentamos um homem de 80 anos, portador de pacemaker, prótese valvular aórtica com endocardite bacteriana prévia (sem intervenção valvular, com substituição do pacemaker), internado por endocardite por Candida metapsilosis. Iniciou caspofungina e voriconazol com persistência de candidemia, alterando-se para anfotericina B e flucitosina, com posterior supressão crónica com itraconazol. Substituiu os elétrodos do pacemaker, porém sem intervenção valvular. Apesar de múltiplas intercorrências, teve alta com boa evolução e sem recorrência no seguimento em ambulatório. Este caso questiona o papel da cirurgia valvular no doente com boa resposta à terapêutica antifúngica isolada, podendo esta última ser considerada tratamento curativo da endocardite fúngica.

Fungal endocarditis is a rare and potentially fatal condition, usually caused by Candida and Aspergillus spp. There is a higher incidence in immunosuppressed patients, patients with previous endocarditis, prosthetic valves or intracardiac devices. Antifungal therapy and surgical approaches are essential as curative intention and to avoid embolic phenomenon. Success cases are rare with medical therapy alone. We present an 80-years-old male patient with a pacemaker and prosthetic aortic valve, previously treated for bacterial endocarditis (without valvular intervention, but with pacemaker replacement), who was diagnosed with fungal endocarditis due to Candida metapsilosis. Although caspofungin and voriconazole were started there was persistent candidemia, leading to the replacement of antifungal, namely liposomal amphotericin B and flucytosine. Chronic suppression with itraconazole followed. The patient was submitted for electrode replacement, but valve intervention was not performed. During the hospital stay, multiple complications occurred but he was discharged with good evolution and no recurrence on follow-up. This case raises the question about the role of valvular intervention on patients whose medical therapy alone is sufficient and could be considered for curative intention for fungal endocarditis.