(P26) A Rare Case of Black Yeast Prosthetic Endocarditis

Chief Complaint : Shortness of breath on exertion and left-sided chest tightness

History of Present Illness : 60 year old male with past medical history of HFrEF (EF 25%, s/p AICD), CAD s/p CABG, bioprosthetic mitral valve repair, presenting with dyspnea on exertion and chest tightness that acutely worsened over 2 days. He describes constant left-sided moderate chest tightness, with no radiation, associated with subjective fevers beginning today. He otherwise denies new complaints. He reports progressive fatigue over the last month to the point where he can only walk a few steps before getting tired. He was told by his primary care doctor last month that his blood pressure was lower than usual and kidney function is worsening. Over the last few days he did not take his home diuretics due to concerns for over-diuresis.

Pertinent Physical Exam: Vitals: T 100.5, HR 105, RR 20, BP: 94/56, O2 sat 98% RA

General: Ill-appearing male, warm to touch
HEENT: jugular venous distension
Heart: Rapid rate, regular rhythm, systolic murmur on apex
Lungs: mild bibasilar crackles
Abdomen: soft, non-tender, distended
Extremities: no lower extremity edema

Pertinent Laboratory Data: WBC 12.3, Hb 8.3
Cr 1.75 BUN 29
Electrolytes wnl
LFTs wnl
Troponin wnl
ESR: 114, CRP: 9.3
UA and UC negative
Blood Cultures: positive for black yeast (Exophiala dermatitidis) in 3 cultures

EKG: sinus tachycardia, no twi, no st changes
CXR: mild pulmonary congestion
Last TTE: moderate mitral prosthesis stenosis.
TTE today: severe mitral prosthesis stenosis. The leaflets appear to be thicker with restricted mobility. There is new anterior leaflet high frequency motion mass on the ventricle side consistent with vegetation.

Case Discussion: Fungal endocarditis accounts for 2-4% of all cases of infective endocarditis, with an exceptionally high mortality rate of 30-50%. It is most commonly seen in patients with prosthetic heart valves, as in this patient. Diagnosis typically involves blood cultures displaying persistent fungemia with vegetations on echocardiography, however, blood cultures can be negative in up to 50% of cases despite vegetations present on echocardiography. For this reason diagnosis of fungal infection is often difficult.

Due to its high mortality rate, current management recommendations involve early valve surgery and often lifelong suppressive anti-fungal therapy. Several studies have shown lower mortality rates with early surgical intervention, with relapse occurring 40% of the time despite surgical resection. This patient was found to have Exophiala dermatitidis prosthetic valve endocarditis and underwent redo sternotomy with a mitral valve replacement with valve cultures growing this fungus. Current literature on post-surgical treatment of this organism is limited, warranting further investigation. This patient will likely require 6 weeks of dual anti-fungal therapy followed by life-long triazole therapy depending on final culture susceptibilities.

Although a diagnosis of fungal endocarditis is rare, as Emergency Medicine physicians it is important for us to consider this in our differential diagnosis of patients presenting with vague symptoms of endocarditis. Early Infectious Disease consultation is also beneficial, particularly in those patients with negative bacterial cultures where a clear cut diagnosis has yet to be made.

References and Acknowledgements (Optional): Ammannaya GKK, Sripad N. Fungal endocarditis: what do we know in 2019? Kardiol Pol. 2019 Aug 23;77(7-8):670-673. doi: 10.33963/KP.14869. Epub 2019 Jun 19. PMID: 31215523.

Butt K, Kumar R, D'Souza J, Limback J, Shah R, Burt J. Catastrophic Prosthetic Valve Endocarditis Caused by Rare Black Fungi. Case Rep Cardiol. 2018 Sep 30;2018:1758539. doi: 10.1155/2018/1758539. PMID: 30364065; PMCID: PMC6186373.

Donal E, Abgueguen P, Coisne D, Gouello JP, McFadden EP, Allal J, Corbi P. Echocardiographic features of Candida species endocarditis: 12 cases and a review of published reports. Heart. 2001 Aug;86(2):179-82. doi: 10.1136/heart.86.2.179. PMID: 11454836; PMCID: PMC1729846.

Mamtani S, Aljanabi NM, Gupta Rauniyar RP, Acharya A, Malik BH. Candida Endocarditis: A Review of the Pathogenesis, Morphology, Risk Factors, and Management of an Emerging and Serious Condition. Cureus. 2020 Jan 18;12(1):e6695. doi: 10.7759/cureus.6695. PMID: 32104631; PMCID: PMC7026878.

Ojha N, Dhamoon AS. Fungal Endocarditis. [Updated 2022 Jul 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

Samuel Seitler, Charo Bruce, Ulrich Rosendahl, Elena Crucerescu, Darryl Shore, Justyna Rybicka, Thomas Semple, Wei Li, Michael A. Gatzoulis, Nada Al-Sakini, Don’t Stop Beleafing: A Unique Case of Fungal Infective Endocarditis, JACC: Case Reports, Volume 3, Issue 4, 2021, Pages 672-677, ISSN 2666-0849.

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