Woman with dyspnea and hypoxia.

Abstract

A 48-year-old female with a history of recent admission for a prolonged COVID course including a period of time on extracorporeal membrane oxygenation (ECMO), presented to our emergency department with complaints of worsening dyspnea on exertion. She was noted to have normal oxygen saturation at rest but would become significantly hypoxic to 70% with minimal exertion. Lab work at presentation was notable for leukocytosis to 25,000 without lactic acidosis. A computed tomography angiography was performed (Figure 1), as well as a bedside point-of-care ultrasound (Figure 2 and Video). Candida albicans infective endocarditis of the tricuspid valve with embolus-in-transit and right main pulmonary artery embolism. Cardiology was immediately consulted with concerns for pulmonary embolism with clot-in-transit. They performed an aspiration embolectomy and concluded that the mass was instead a large vegetation secondary to Candida albicans. She previously had candidemia while on ECMO and completed a course of fluconazole with presumed clearance of infection. After the procedure, the patient developed severe tricuspid regurgitation requiring tricuspid valve replacement and an extended course of micafungin therapy. Candida infective endocarditis (CIE) is a rare complication with a reported prevalence ranging from 1.9% to 5.9% in patients with candidemia.1 In 2017, there were roughly 23,000 cases of candidemia.2 Those with underlying valvular heart disease (native and prosthetic) are at an increased risk consistent with findings for bacterial IE, though fungal endocarditis makes up roughly 1%–10% of cases of IE.1, 3 Overall mortality associated with CIE is close to 50%, almost double the mortality of candidemia alone.1, 2 Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.