Invasive Aspergillosis Manifesting As An Intracardiac Mass In A Heart Transplant Patient

Abstract

<h3>Introduction</h3> Invasive aspergillosis (IA) is the third most common form of invasive fungal infections in immunocompromised patients, and has the second highest mortality rate at 30-70%. Invasion of lung parenchyma is the most common presentation, but can rarely present as aspergillus endocarditis. To our knowledge, IA presenting as a mass lesion in the heart is very rare and has never been reported in an orthotopic heart transplant (OHT) patient. We present a case of invasive aspergillus manifesting as an intracardiac mass in the right atrium (RA) in a heart transplant patient who survived. <h3>Patient presentation</h3> This is a 68 year-old-male with ischemic cardiomyopathy s/p OHT in June 2019 complicated by Aspergillus fumigatus sternal osteomyelitis requiring complete sternectomy on chronic antifungal therapy who was readmitted for right shoulder pain and failure to thrive. On admission, the patient was afebrile and hemodynamically stable. Pertinent workup showed transthoracic echocardiogram (TTE) with right atrial (RA) mass confirmed to be 3.5 × 3.3 cm by transesophageal echocardiogram (TEE) attached to interatrial septum. Initial malignancy workup was negative. Further infectious work up was remarkable for Aspergillus antigens. Intra-cardiac echocardiogram (ICE) and TEE techniques were utilized to locate and culture the mass. Argon epitome was placed into the mass under fluoroscopic and intracardiac echo guidance, extracting two specimens. Gross examination suggested identical specimens without any evidence of endocardium or lipomatous tissue. Initial pathology showed findings consistent with a thrombus but no evidence of fungal organisms, inflammation or malignancy. However, cultures from the specimen revealed Aspergillus fumigatus. Unfortunately, the patient was deemed a poor surgical candidate for resection due to other comorbidities and attempts are being made for long term antifungal therapy in management. <h3>Discussion</h3> Opportunistic infections such as invasive fungal infections are the leading cause of mortality in heart transplant recipients. Approximately 65% of OHT cases will have an infection within the first year of surgery. In a single institution, both incidence and mortality of IA in heart transplant recipients declined over the years. Despite this decrease, it remains a common pathogen observed in immunocompromised populations, specifically in solid organ transplantations. Most IA present as pulmonary disease as the route of entry for aspergillus conidia particles is inhalation, but rarely has intracardiac manifestations. To our knowledge, this is the first case report of invasive aspergillosis in a heart transplant recipient who had rare systemic manifestations including intra-cardiac mass and sternal osteomyelitis.