Review
Aspergillus Endocarditis After Cardiac Surgery

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Aspergillus species infections are an increasingly common occurrence in hospital wards. Aspergillus endocarditis constitutes one of the manifestations of the disease, which bears a poor prognosis in cardiac surgery patients. A review of the literature on fungal and Aspergillus endocarditis was undertaken. Valvular risk factors, indwelling intravenous catheters, prolonged antibiotics, malignancy, and intravenous drug use increase the risk. Clinical presentation is insidious, with embolic complications often representing the first manifestation of the disease. Blood cultures are typically negative. The mortality rate is almost 100%. Amphotericin B represents the mainstay of medical therapy with several possible adjuncts. Surgery is an essential part of therapy in Aspergillus endocarditis after cardiac surgery and should be undertaken as soon as the diagnosis is made. Aspergillus endocarditis is an ominous complication after cardiac surgery. A high suspicion index, early administration of appropriate antibiotics, and prompt surgical intervention should improve the prognosis, which remains dismal.

Section snippets

Historical Perspective

The Aspergillus species was initially described by Micheli in 1729. The first case of Aspergillus disease in humans was reported in the mid 1800s. Hadorn described a case of Aspergillus aortitis in 1960. In 1964, Newman and Cordell reported the first case of Aspergillus endocarditis (AE) after mitral valvulectomy, which ended with the death of the patient soon after disease presentation and establishment of the diagnosis of AE postmortem. Amphotericin B has been the mainstay of therapy for the

Material and Methods

We conducted a literature search using the Pubmed-Medline database. We reviewed all articles in French or English from 1970 to today. Search terms used were “Aspergillus,” “Aspergillus endocarditis,” “cardiac surgery,” and “fungal endocarditis.” All articles, including isolated case reports, were reviewed.

Epidemiology

Aspergillus endocarditis is increasingly prevalent among hospitalized patients nowadays due, in part, to the increasing use of intracardiac devices [2]. Fungal endocarditis affects approximately 0.1% of all prosthetic valves [3] and the Aspergillus species contributes to approximately 25% of all cases of fungal endocarditis [1], second only to the Candida species with an Aspergillus to Candida ratio of 1:3 to 1:2 [1, 4]. Men are more commonly affected than women with a peak incidence during the

Microbiology

Numerous strands of Aspergillus have been identified, and the most commonly responsible for AE include Aspergillus fumigatus (60% to 90%), Aspergillus terreus (5% to 20%), Aspergillus flavus, Aspergillus niger, and Aspergillus nidus [7]. The predominance of one of these species owes to several intrinsic characteristics that vary from one strand to the other including mass doubling time, viability at body temperature as most species do not survive at 37°C [9], production of proteases, and

Sources and Risk Factors

Aspergillus infection may be community-acquired or may occur as a nosocomial event. The primary ecologic niche for Aspergillus species is vegetable material and soil [16, 17], but it may reside anywhere from water to food (tea, fruits, peppers, and spices) to potted plants and flowers as well as ice-making machines and air humidifiers. Air remains the principal means of transmission to patients, especially in cases of AE. Molds release an extremely high number of small-sized conidia (3 μm to 5

Clinical Presentation

Typically, AE presents with a relative paucity of peripheral signs of endocarditis (ie, Osler’s nodes, Janeway lesions, Roth spots) [30]. No consistent or pathognomonic features characterize AE. The most common clinical features are fever, major peripheral emboli, and a changing heart murmur [5]. Less commonly, patients present with focal or generalized neurologic deficits, heart failure, or dyspnea [1].

The interval between valve replacement and onset of infection is extremely variable, ranging

Complications

As already mentioned, major peripheral emboli are one of the most common presenting features of AE and occur in as many as 83% of patients with AE, averaging 68% of patients [31]. Peripheral emboli may lodge in the brain, skin, eyes, upper and lower limbs, mesenteric arteries, kidneys, and coronary artery beds, hence mimicking other pathologic conditions and contributing to delaying the diagnosis in some cases. The occurrence of emboli in a culture-negative environment should raise the

Diagnosis

The most critical step in the treatment of AE is establishing the diagnosis in a timely fashion, a difficult task that hampers therapeutic success. Several complementary methods can be used to establish the diagnosis of AE.

Treatment

Another stumbling area of modern medicine in the management of AE pertains to the therapeutic strategy to adopt in the face of such a complication. Therapeutic management conventionally consists of combined medical and surgical approaches whenever possible. However, despite years of wrestling with the disease with dismal results, very few advances have been introduced in the management of AE, and mortality rates remain extremely high.

Conclusion

Aspergillus endocarditis is an ominous complication after cardiac surgery with a dismal prognosis despite better understanding of the etiology of the disease. Its detection and eradication from the hospital environment, its diagnosis in patients, and the therapeutic arsenal available remain major limiting factors for obtaining better short- and long-term results. A multidisciplinary approach is therefore warranted when outbreaks of AE are encountered to act swiftly on the primary prevention of

References (59)

  • I. El-Hamamsy et al.

    A cluster of cases of aspergillus endocarditis after cardiac surgery

    Ann Thorac Surg

    (2004)
  • A. Sanchez-Recalde et al.

    Aspergillus aortitis after cardiac surgery

    J Am Coll Cardiol

    (2003)
  • Z. Erjavec et al.

    Recent progress in the diagnosis of fungal infections in the immunocompromised host

    Drug Resist Update

    (2002)
  • E. Rubinstein et al.

    Tissue penetration of amphotericin B in candida endocarditis

    Chest

    (1974)
  • M.E. Ellis et al.

    Fungal endocarditisevidence in the world literature, 1965–1995

    Clin Infect Dis

    (2001)
  • E. Rubinstein et al.

    Fungal endocarditis

    Eur Heart J

    (1995)
  • L.C. Pierotti et al.

    Fungal endocarditis, 1995–2000

    Chest

    (2002)
  • T. Gumbo et al.

    Aspergillus valve endocarditis in patients without prior cardiac surgery

    Medicine

    (2000)
  • J.I. Pitt

    The current role of Aspergillus and Penicillium in human and animal health

    J Med Vet Mycol

    (1994)
  • J.P. Bouchara et al.

    Extracellular fibrinogenolytic enzyme of Aspergillus fumigatussubstrate-dependent variations in the proteinase synthesis and characterization of the enzyme

    FEMS Immunol Med Microbiol

    (1993)
  • J.F. Chris Tomee et al.

    Proteases from Aspergillus fumigatus induce release of proinflammatory cytokines and cell detachment in airway epithelial cell lines

    J Infect Dis

    (1997)
  • A. Mullbacher et al.

    Identification of an agent in cultures of Aspergillus fumigatus displaying anti-phagocytic and immunomodulating activity in vitro

    J Gen Microbiol

    (1985)
  • G.T. Stavridis et al.

    Aspergillus prosthetic valve endocarditis

    Eur J Cardiothorac Surg

    (1993)
  • A. Goncalves Rodrigues et al.

    Adhesion of Aspergillus spp to biomaterials

    Clin Micro Infect

    (2002)
  • T.J. Walsh et al.

    Nosocomial aspergillosisenvironmental microbiology, hospital epidemiology, diagnosis and treatment

    Eur J Epidemiol

    (1989)
  • T.J. Walsh

    Invasive aspergillosis in patients with neoplastic diseases

    Sem Resp Infect

    (1990)
  • C.S. Clark et al.

    Levels of gram-negative bacteria, Aspergillus fumigatus, dust, and endotoxin at compost plants

    Appl Environ Microbiol

    (1983)
  • J.R. Lentino et al.

    Nosocomial aspergillosisa retrospective review of airborne disease secondary to road construction and contaminated air conditioners

    Am J Epidemiol

    (1982)
  • J.J. Weems et al.

    Construction activityan independent risk factor for invasive aspergillosis and zygomycosis in patients with hematologic malignancy

    Infect Control

    (1987)
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