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Invasive Aspergillus infections complicating coronary artery bypass grafting
1Department of Medicine, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem NC 27103.
Abstract:
Endovascular infection with Aspergillus species results in unacceptably high mortality of greater than 80% in most series. Failure to recognize the infection early during its clinical course contributes to its formidable lethality. Blood cultures almost never reveal organisms, as in our Cases 1 and 2. When considering a patient with fever, changing murmur, major systemic emboli, or splenomegaly, and with blood cultures negative for organisms months or even years after cardiac surgery, therefore, the physician should maintain a high index of suspicion for fungal endocarditis. The best opportunity to establish the diagnosis antemortem rests in careful histopathologic and microbiologic examination of infected emboli and vegetations. Most authors agree that a combined approach employing early valve replacement and aggressive antifungal chemotherapy with amphotericin B and perhaps flucytosine or rifampin represents the best option for treatment of endovascular Aspergillus infections.
Insights
Fungal endocarditis caused by Aspergillus species has a high mortality rate. Early diagnosis through histopathology and prompt treatment with antifungal chemotherapy and valve replacement are crucial for improving patient outcomes.
Area of Science:
- Cardiology
- Infectious Diseases
- Mycology
Background:
- Endovascular infections by Aspergillus species are associated with over 80% mortality.
- Delayed diagnosis significantly contributes to the high lethality of fungal endocarditis.
Observation:
- Aspergillus endocarditis often presents with non-specific symptoms like fever, changing murmurs, systemic emboli, or splenomegaly.
- Blood cultures are frequently negative, complicating early identification of the causative organism.
Findings:
- Histopathologic and microbiologic examination of infected emboli and vegetations offer the best chance for antemortem diagnosis.
- Aggressive antifungal chemotherapy (amphotericin B, flucytosine, rifampin) combined with early valve replacement is the recommended treatment strategy.
Implications:
- High index of suspicion is necessary for patients with relevant symptoms and negative blood cultures post-cardiac surgery.
- Multidisciplinary approach involving cardiologists, infectious disease specialists, and surgeons is vital for managing Aspergillus endocarditis.
- Improved diagnostic strategies and timely intervention can potentially reduce the mortality associated with this severe infection.