Authors' Affiliations

Ashwin Jagadish, Department of Internal Medicine, East Tennessee State University James H. Quillen College of Medicine, PO Box 70622 Johnson City, TN 37614 USA Nasir Notta, Department of Internal Medicine, East Tennessee State, University James H. Quillen College of Medicine, PO Box 70622 Johnson City, TN 37614 USA Hezborn Magacha, Department of Internal Medicine, East Tennessee, State University James H. Quillen College of Medicine, PO Box 70622 Johnson City, TN 37614 USA Sean Moore, Department of Internal Medicine, East Tennessee State University James H. Quillen College of Medicine, PO Box 70622 Johnson City, TN 37614 USA Sabahuddin Hajjar, Department of Internal Medicine, East Tennessee State University James H. Quillen College of Medicine, PO Box 70622 Johnson City, TN 37614 USA Mohannad Al Akeel, Department of Internal Medicine, East Tennessee State University James H. Quillen College of Medicine, PO Box 70622 Johnson City, TN 37614 USA

Location

D.P. Culp Center Ballroom

Start Date

4-5-2024 9:00 AM

End Date

4-5-2024 11:30 AM

Poster Number

9

Name of Project's Faculty Sponsor

Joel Danisi

Faculty Sponsor's Department

Internal Medicine

Classification of First Author

Medical Resident or Clinical Fellow

Competition Type

Non-Competitive

Type

Poster Presentation

Presentation Category

Science, Technology and Engineering

Abstract or Artist's Statement

Introduction Fungal endocarditis (FE) is a relatively uncommon and challenging form of endocarditis, making up a modest percentage of infectious endocarditis cases, ranging from 1.3% to 6%.1 While Candida albicans has historically been recognized as a common causative agent, the landscape is evolving, with Candida parapsilosis (C. parapsilosis) emerging as a prevalent non-albicans species associated with this condition. Recent data show FE prevalence rising to 2-5% of endocarditis cases, highlighting evolving epidemiology. We present a rare case of C. parapsilosis endocarditis, contributing to understanding the changing fungal pathogen landscape in cardiovascular infections. By highlighting this unique instance of Candida parapsilosis endocarditis, we contribute to a deeper understanding of the complexities associated with fungal endocarditis, emphasizing the need for ongoing research and vigilance in diagnosing and managing these challenging infections within the realm of cardiovascular health. Case The patient was a 73-year-old male with a past medical history of history of heart failure with reduced ejection fraction (35-40%), paroxysmal atrial fibrillation, dilated ischemic cardiomyopathy, and thoracic aortic aneurysm. Three years and five months before presentation, he underwent MitraClip© mitral valve repair due to severe mitral regurgitation caused by a myxomatous mitral valve and flail posterior leaflet. He experienced two episodes of Candida parapsilosis fungemia post-procedure, leading to a daily prophylactic regimen of 400 mg oral fluconazole. He presented with worsening left upper quadrant abdominal pain, and imaging revealed a splenic infarct, suggesting septic emboli. Transthoracic echocardiogram showed reduced ejection fraction without obvious valvular vegetations. Upon consultation, he was started on daptomycin, cefepime, and micafungin. Blood cultures confirmed C. parapsilosis fungemia on day 3, prompting adjustments to his antifungal regimen. A transesophageal echocardiogram revealed mobile mass lesions on the atrial surface of the anterior mitral leaflet, with the largest mass measuring 1.1 cm. He was referred for surgical evaluation. Discussion Due to previous modification of the mitral and aortic valves, patients with prosthetic implants or valves are more susceptible to C. parapsilosis infection. Fungal endocarditis has a significant morbidity and mortality rate, hence early identification and treatment are essential. Echocardiography is used to identify lesions, which are usually seen on the left side of the heart, and Mannan antigen testing is used in conjunction with blood cultures to aid in diagnosis. Because of their potency against biofilms, echinocandins such as micafungin are recommended as first line of treatment. Another treatment option is voriconazole, particularly in cases of prophylactic fluconazole failure. Patients who have received prior treatment might benefit from echinocandin sensitivity testing. Complications such as embolism risk, chronic infection, or heart failure may warrant surgery. Our case is the first documented example of Candida parapsilosis endocarditis in a patient receiving long-term preventative fluconazole medication, despite the fact that infective endocarditis associated with MitraClip© usually includes bacterial pathogens. Conclusion Although fungal endocarditis is relatively uncommon, it is an important differential diagnosis to consider in patients with MitraClip©. Treatment with echinocandin antifungal agents is considered to be an effective option. In some patients, however, surgical intervention may be required.

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Apr 5th, 9:00 AM Apr 5th, 11:30 AM

Candida parapsilosis Endocarditis in a Patient With Mitral Valve Clip Receiving Chronic Fluconazole Therapy

D.P. Culp Center Ballroom

Introduction Fungal endocarditis (FE) is a relatively uncommon and challenging form of endocarditis, making up a modest percentage of infectious endocarditis cases, ranging from 1.3% to 6%.1 While Candida albicans has historically been recognized as a common causative agent, the landscape is evolving, with Candida parapsilosis (C. parapsilosis) emerging as a prevalent non-albicans species associated with this condition. Recent data show FE prevalence rising to 2-5% of endocarditis cases, highlighting evolving epidemiology. We present a rare case of C. parapsilosis endocarditis, contributing to understanding the changing fungal pathogen landscape in cardiovascular infections. By highlighting this unique instance of Candida parapsilosis endocarditis, we contribute to a deeper understanding of the complexities associated with fungal endocarditis, emphasizing the need for ongoing research and vigilance in diagnosing and managing these challenging infections within the realm of cardiovascular health. Case The patient was a 73-year-old male with a past medical history of history of heart failure with reduced ejection fraction (35-40%), paroxysmal atrial fibrillation, dilated ischemic cardiomyopathy, and thoracic aortic aneurysm. Three years and five months before presentation, he underwent MitraClip© mitral valve repair due to severe mitral regurgitation caused by a myxomatous mitral valve and flail posterior leaflet. He experienced two episodes of Candida parapsilosis fungemia post-procedure, leading to a daily prophylactic regimen of 400 mg oral fluconazole. He presented with worsening left upper quadrant abdominal pain, and imaging revealed a splenic infarct, suggesting septic emboli. Transthoracic echocardiogram showed reduced ejection fraction without obvious valvular vegetations. Upon consultation, he was started on daptomycin, cefepime, and micafungin. Blood cultures confirmed C. parapsilosis fungemia on day 3, prompting adjustments to his antifungal regimen. A transesophageal echocardiogram revealed mobile mass lesions on the atrial surface of the anterior mitral leaflet, with the largest mass measuring 1.1 cm. He was referred for surgical evaluation. Discussion Due to previous modification of the mitral and aortic valves, patients with prosthetic implants or valves are more susceptible to C. parapsilosis infection. Fungal endocarditis has a significant morbidity and mortality rate, hence early identification and treatment are essential. Echocardiography is used to identify lesions, which are usually seen on the left side of the heart, and Mannan antigen testing is used in conjunction with blood cultures to aid in diagnosis. Because of their potency against biofilms, echinocandins such as micafungin are recommended as first line of treatment. Another treatment option is voriconazole, particularly in cases of prophylactic fluconazole failure. Patients who have received prior treatment might benefit from echinocandin sensitivity testing. Complications such as embolism risk, chronic infection, or heart failure may warrant surgery. Our case is the first documented example of Candida parapsilosis endocarditis in a patient receiving long-term preventative fluconazole medication, despite the fact that infective endocarditis associated with MitraClip© usually includes bacterial pathogens. Conclusion Although fungal endocarditis is relatively uncommon, it is an important differential diagnosis to consider in patients with MitraClip©. Treatment with echinocandin antifungal agents is considered to be an effective option. In some patients, however, surgical intervention may be required.