Fungal endocarditis: clinical predictors for early diagnosis aiming at better outcome

Abstract

Purpose: To study the clinical characteristics of patients with definite fungal endocarditis (FE) aiming at detecting clinical predictors for early diagnosis. Fungal endocarditis is a devastating disease that is associated with multiple morbidities and high mortality. Diagnosis is difficult and usually very late. Early diagnosis and treatment may result in better outcome. Method: Retrospective analytic study that included 232 patients with definite IE in the period between February 2005 and September 2011. Results: 31 (13.3%) patients had FE. The whole group was relatively young with mean age of 35 (13-74) in FE and 28.5 (15-50) in non-FE group. In the FE group 22 cases had aspergillus, 6 cases had candida [71% vs. 19.3%, p < 0.001] and 3 had other fungi. Native RHD was less prevalent in FE group [9.7% vs. 42.8%, p < 0.001; OR: 0.1, 95% CI = 0.04-0.49)]. The FE group had more cardiac prostheses [74.2% vs 23.8%, p <0.001; OR: 9.18, 95% CI = 3.8-21.9)]. Early P.V.E. was more prevalent among FE group [64% vs 38%, p=0.059], late P.V.E. was more common in non-FE [61% vs 36%, p=0.059]. Cardiac vegetations were more common FE group 100% vs. versus 84.6% in the non-FE group (p=0.002). Vegetations in FE group were larger [20 mm vs. 12 mm, p=0.002]. Negative Bl. Culture was more common among FE [80.6% vs. 52%, p=0.003]. HAI (identified as: infection [contracted ≥48 hours after hospital admission, infection appearing within: a) 1 month of receiving IV cannulation, chemotherapy or dialysis; b) 3 months of admission into an acute care facility, c) any time of admission to a nursing home) was significantly more common in FE group 90.3% vs. 58.2%, p=0.001; OR: 6.7, 95% CI = 1.98-22.9)]. Complications were high in both groups, however death was significantly higher in FE [(54.8%) vs. 66 (32.8%), p=0.017]. Through multivariate regression test following variables were independently associated with fungal IE: presence of cardiac prosthesis [OR: 14, 95% CI: 5 to 41, p<0.001] , presence of HAI [OR: 8, 95% CI: 2 to 29, p=0.003], non-presence of splenomegaly [OR: 0.174, 95% CI: 0.034 to 0.879, p=0.034] and the patient being IVDU [OR: 12, 95% CI: 2 to 64, p=0.004]. Also the larger the vegetation size [CI: 0.011-0.002, p=0.003]. Conclusion: Looking for clinical characteristics might help in the diagnosis of FE which is a disease associated with negative blood culture and grave prognosis. The association of cardiac prosthesis, HAI, large vegetation, IVDU and absence of splenomegaly in a culture negative IE might help this diagnosis.