Fungal prosthetic mitral valve endocarditis caused by Scopulariopsis species: Case report and review of the literature

Abstract

Clinical Summary A 67-year-old woman with a past medical history significant for rheumatic fever, gout, pulmonary hypertension, atrial fibrillation, congestive heart failure, and 3 prior valve operations presented with fever and right leg pain. One year before presentation she underwent replacement of her aortic and mitral valves with a 19-mm Carpentier-Edwards Magna pericardial valve and a 25-mm Carpentier-Edwards pericardial valve (Baxter Healthcare Corp, Edwards Lifesciences, Irvine, Calif), respectively. Her social history was significant for pet finches. Her temperature was 101°F, she had a systolic murmur at the left sternal border, and her right foot was cold with diminished pulses. She had no evidence of onychomycosis or peripheral emboli. Abdominal computed tomography demonstrated a nonocclusive clot in the right ileac artery. Hematologic parameters and chemistries were normal. Blood cultures, including fungal isolator blood cultures incubated over 4 weeks, were negative. After the patient’s left leg became cold and pulseless, she urgently underwent thromboendarterectomy of an acutely occluded femoral artery. Pathology from the embolectomized specimen demonstrated septated hyphal elements. Subsequently on day 5, fungal cultures grew a mold morphologically identified as a Scopulariopsis species (Figure 1). She underwent a transesophageal echocardiogram revealing a larger than 12-mm vegetation on the mitral valve with moderate mitral regurgitation. Confirmatory identification and susceptibility testing performed at Focus Diagnostics (Cyprus, Calif) identified the organism as S brevicaulis and demonstrated mean inhibitory concentrations of 4 g/mL to amphotericin B, 1 g/mL to terbinafine, 8 g/mL to voriconazole, and greater than 8 g/mL to itraconazole. The patient underwent excision of the senescent infected mitral valve pericardial prosthesis, extensive debridement of the associated fungal vegetation, and a mitral valve replacement with a Carpentier-Edwards pericardial valve. She was treated preoperatively and postoperatively with amphotericin B and voriconazole. The amphotericin was continued for 3 weeks postoperatively, and the voriconazole was arbitrarily continued for 11 weeks until the patient could not tolerate it because of debilitating nausea. She had a complicated respiratory course postoperatively and was discharged to a rehabilitation facility. She was subsequently readmitted with dyspnea and died 5 months after initial presentation without signs of recurrent infection. Culture of her pet finch’s feathers grew Aspergillus species and not Scopulariopsis species, despite the mold’s propensity to grow in bird feathers.