Candidal endocarditis presenting with bilateral lower limb ischemia

The incidence of fungal endocarditis is increasing. While the pathogenic mechanisms are not fully understood, infection is associated with underlying heart disease and is most often attributable to Candida species. Candidal endocarditis complications include heart damage, inflammation, and emboli with resulting ischemia and tissue death. Candidal endocarditis is difficult to diagnose as blood cultures are often negative. Treatment includes surgical intervention and antifungal therapy. This case study describes a 41-year-old female complaining of acute onset of pain with numbness and tingling in both lower extremities. Prior history was significant for mycotic valve aneurysm and replacement secondary to culture-negative endocarditis. Evidence of limb-threatening ischemia led to a bilateral thrombectomy. During the thrombectomy white debris, later identified as Candida albicans, was encountered. A transesophogeal echocardiogram revealed a pedunculated mass which was determined to be the source of infection. The patient was placed on micafungin and voriconazole and discharged with a diagnosis of C. albicans fungal infection with descending aorta fungal mass. This case study illustrates an unusual presentation of candidal endocarditis with discussion of disease epidemiology, pathogenesis, diagnosis, and treatment.