Co-infection with bacterial and fungal endocarditis at scar tissue in an immunocompromised patient

We present the case of a 65-year-old immunocompromised male with a history of kidney transplantation, diabetes, coronary artery bypass, and cardiac resynchronization therapy device implantation who was finally diagnosed with an unusual form of infective endocarditis due to co-infection of fungal and bacterial pathogens. He was afebrile at the time of admission and presented with decompensated heart failure and pneumonia. A spleen abscess was discovered incidentally and prompted us to search for a cardiac source of emboli. Culture of the suppurative fluid drained percutaneously from the abscess was positive for Enterococcus and Aspergillus species. Transthoracic and transesophageal echocardiography revealed a mobile vegetation attached to the scarred myocardium of anterior septum - an unusual location for intracardiac vegetations. With regard to the prohibitive risk for redo surgery, the patient was managed medically with broad spectrum antimicrobial therapy. Finally, the patient died with severe sepsis. <Learning objective: Immunocompromised patients are at risk of opportunistic infections such as fungal endocarditis. Co-infection of fungal and bacterial pathogens is very rare. Early diagnosis of such infections needs a high level of clinical suspicion due to its non-specific presentations and culture negative essence. Many patients are afebrile during the disease course. Fungal endocarditis is characterized by large vegetations highly prone to systemic embolization even in the early stages of infection. Mortality is high despite optimal antimicrobial and timely surgery.>.