Late Failure of Surgical Treatment for Bioprosthetic Valve Endocarditis Due to Candida tropicalis

Abstract

Late treatment failures may occur after surgical treatment of endocarditis due to Candida species [1,2] and Pseudomonas spe­ cies [3]; this finding suggests that cure should not be assumed until long-term follow-up has been completed. Failures occurring from 9 months [1] to 7 years [2] after surgical treatment have been reported for intravenous drug users, and such failures have occurred after 6 months in patients who did not use intravenous drugs [1]. We report a case of Candida tropicalis endocarditis in a patient who was not an intravenous drug user; this patient had a probable relapse 44 months after surgery. A 50-year-old man with chronic rheumatic valvular disease un­ derwent aortic valvuloplasty and mitral valve replacement with a bovine pericardial bioprosthesis. Routine culture of the implanted prosthesis was sterile. After the operation, mild aortic insufficiency was noted; fever, pericardial and pleural friction rubs, and atrial fibrillation ensued. The diagnosis ofpostpericardiotomy syndrome was made, and treatment with indomethacin (150 mg daily) was initiated. The patient defervesced and was discharged. The fever relapsed after therapy with indomethacin was discon­ tinued, and the patient was readmitted to the hospital 73 days after discharge (81 days after surgery). On physical examination, aortic insufficiency and splenomegaly were observed. Findings on an echocardiogram were suggestive of vegetations on the prosthesis. After blood for cultures was drawn, therapy with penicillin and streptomycin was started; however, seven of eight sets of blood cultures later yielded C. tropicalis. Antibiotic therapy was changed to that with amphotericin B, and the patient underwent surgery 2 days later. At surgery, rupture of the bioprosthesis and vegetations on the atrial surface of the leaflets were detected; however, there was no involvement ofthe mitral annulus, and aortic valve insuffi­ ciency without endocarditis was noted. The bioprosthesis and the valve were replaced with two bovine pericardial prostheses. Cul­ ture of the excised prosthesis yielded Candida species, although culture of the aortic valve was sterile. Histologic examination of sections of the prosthesis revealed numerous hyphae and spores compatible with a Candida species. A total dose of 2.1 g ofampho­ tericin B (50 mg/d) was administered over 6 weeks. The patient was discharged on the 59th postoperative day, and no evidence of metastatic infection was detected on follow-up.