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Successful medical treatment of presumed Candida endocarditis in critically ill infants
P N Zenker1, E M Rosenberg, R B Van Dyke
1Department of Pediatrics, Tulane University Medical Center, New Orleans, Louisiana.
Abstract:
Few infants have been reported who survived fungal endocarditis; all have required both surgical and intensive antifungal therapy. We describe three infants, two weighing less than 1000 gm, who survived Candida endocarditis without surgery. Two had Candida parapsilosis, an agent not previously reported as a cause of neonatal endocarditis. All three infants were treated with amphotericin B and 5-flucytosine. Despite administration of 44, 38, and 48 mg/kg amphotericin B, respectively, no nephrotoxicity was noted; 5-flucytosine therapy was stopped in one infant because of thrombocytopenia. One infant died of an unrelated cause 6 months later; there was no evidence of Candida or endocarditis at autopsy. The other two infants are thriving 2 and 3 years after the completion of antifungal therapy; no remaining evidence of endocarditis is present on echocardiography. We conclude that antifungal therapy without surgery is an option for Candida endocarditis in critically ill infants.
Insights
Critically ill infants with fungal endocarditis can survive without surgery. Antifungal therapy alone, using amphotericin B and 5-flucytosine, offers a viable treatment option for Candida endocarditis in neonates.
Area of Science:
- Neonatal Medicine
- Infectious Diseases
- Pediatric Cardiology
Background:
- Fungal endocarditis in infants is rare and typically requires surgical intervention and intensive antifungal treatment for survival.
- Previous reports indicate a poor prognosis for neonates diagnosed with fungal endocarditis.
Observation:
- This study reports on three premature infants (two under 1000 gm) who survived Candida endocarditis without requiring surgery.
- Two cases involved Candida parapsilosis, a previously unreported cause of neonatal endocarditis.
Findings:
- All three infants received a combination of amphotericin B and 5-flucytosine.
- Despite high doses of amphotericin B, no nephrotoxicity was observed. One infant experienced thrombocytopenia, leading to discontinuation of 5-flucytosine.
- Long-term follow-up showed two infants thriving with no echocardiographic evidence of endocarditis; one infant died of unrelated causes with no autopsy findings of fungal endocarditis.
Implications:
- Antifungal therapy alone may be a successful treatment strategy for Candida endocarditis in critically ill infants, potentially avoiding invasive surgery.
- The findings suggest that Candida parapsilosis should be considered in neonatal endocarditis cases.
- This approach may improve outcomes for neonates with fungal endocarditis, particularly those with significant comorbidities or where surgery poses a high risk.
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