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Aspergillus niger Aortitis after Aortic Valve Replacement Diagnosed by Transesophageal Echocardiography Hamza Duygu, M.D.,∗ Sanem Nalbantgil, M.D.,∗ Filiz Ozerkan, M.D.,∗ Bahadir Kirilmaz, M.D.,∗ and Tahir Yagdi, M.D.† ∗
Department of Cardiology and †Department of Cardiovascular Surgery, Ege University Medical Faculty, Izmir, Turkey Aspergillus aortitis following cardiac surgery has an important role among the cardiac infections as almost all affected cases result in death. Survival of the patient with Aspergillus aortitis is dependent on early initiation of aggressive medical and surgical treatment. Transesophageal echocardiography proved very useful in the diagnosis of this uncommon case of aortitis. In this paper, we present a patient with aortitis caused by Aspergillus niger that hasn’t been reported previously diagnosed by transesophageal echocardiography following cardiac surgery. (ECHOCARDIOGRAPHY, Volume 23, May 2006) aortitis, aortic valve replacement, transesophageal echocardiography Case Report A 50-year-old woman with the diagnosis of rheumatic valve disease presented with high fever. She has been in a dialysis program for chronic renal failure since last 8 years. She suffered from culture-negative aortic valve endocarditis and underwent mechanical aortic valve replacement for severe aortic regurgitation with mechanical valve. The patient developed a fever of 39◦ C, fatigue, and chills 2 months after the aortic valve replacement and hospitalized for further investigation and treatment. Her physical examination revealed a blood pressure of 140/80 mmHg, a pulse rate of 120 per minute, and a fever of 40◦ C. In cardiac auscultation, cardiac sounds were rhythmic and metallic valve sound was heard. Other physical examination findings were normal. On the electrocardiogram there was no abnormality apart from the sinus tachycardia. Her pathological laboratory values were as follows: white blood cell count 32,000/mm3 , erythrocyte sedimentation rate 120 mm/h, blood urea nitrogen 113 mg/dl, and creatinine 5.5 mg/dl.
Address for correspondence and reprint requests: Hamza Duygu, M.D., Associate Fellow of Cardiology, Ege University Medical Faculty, Cardiology Department, Bornova, 35100, Izmir-Turkey. Fax: +902323903287; E-mail:
[email protected]
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There was no bacterial growth in repeated blood cultures. Empirical antibiotic treatment (vancomycin and gentamicin) was started. Mechanical valve functions were found to be normal on transthoracic echocardiography. A mobile vegetative mass 3.5×3 cm in size extending into the lumen through the pseudoaneurysm in the ascending aorta was seen on transesophageal echocardiography performed upon persistence of the symptoms and signs of the patients (Fig. 1). Upon this, we decided to reoperate the patient. Pseudoaneurysm at the site of prior incision on the ascending aorta and a vegetative mass were observed at the exploration (Fig. 2). Aspergillus niger grew in the blood samples and vegetation was taken intraoperatively. Oral itraconazole treatment was begun following liposomal amphotericin B treatment of 2 weeks and continued for six months. The patient is doing well on her postoperative visits with the following time over two years without any evidence of recurrence. Discussion Mycotic cardiac invasion is usually seen following cardiopulmonary bypass surgery and its incidence is very low.1 Cardiovascular involvement of Aspergillus infections is most commonly in the form of endocarditis. Four cases of endocarditis caused by Aspergillus niger have
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Figure 1. Transesophageal longitudinal plane shows the mobile vegetative mass (small arrow) extending into the lumen through the pseudoaneurysm (large arrow) in the ascending aorta. LA = Left atrium; LV = Left ventricle; AO = Ascending aorta; P = Pseudoaneurysm; V = vegetation. Figure 2. Intraoperative view of the vegetation in the ascending aorta.
been reported.2 Aspergillus infection of the ascending aorta without endocarditis is very rare. Damage to the aortic wall during the aortic cannulation at the time of aortic surgery is the most important factor in the development of Aspergillus aortitis.3,4 Additionally, immunosuppression, implantation of intracardiac prosthetic devices, long-term antibiotic treatment, and intravenous catheter use for a prolonged period also predisposes to the fungal infections. However, among these predisposing factors, only the history of cardiac valve surgery was present in our patient. Inflammatory process leads to the development of an aneurysm by weakening the aortic wall. Aspergillus fumigatus is the most common fungal agent responsible for the Aspergillus aortitis.5 However, the responsible fungus in our patient was Aspergillus niger that has not been reported so far in the literature to cause aortitis. The diagnosis of Aspergillus aortitis is very difficult. Blood cultures are usually negative and the infection may be overlooked by transthoracic echocardiography as it localizes in the ascending aorta. Delays in the treatment from the reasons above increase the mortality rate
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which is over 90%.6 For this reason, fungal aortitis should be considered in the patients presented with persistent high fever following cardiac surgery, especially the aortic valve replacement if no growth occurs in the blood cultures. Therefore, transesophageal echocardiography should be performed promptly. References 1. Kammer RB, Utz JP: Aspergillus species endocarditis: The new face of a not so rare disease. Am J Med 1974;56:506–521. 2. McCracken D, Barnes R, Poynton C, et al: Polymerase chain reaction aids in the diagnosis of an unusual case of Aspergillus niger endocarditis in a patient with acute myeloid leukaemia. J Infect 2003;47:344–347. 3. Middleton J, Chmel H, Tecson F, et al: Aortotomy site infections case presentation and review of the literature. Am J Med Sci 1980;279:105–109. 4. Jenckes GA: Aspergillus aortitis. J Thorac Cardiovasc Surg 1990;99:375–376. 5. Recalde AC, Mate I, Merino JL, et al: Aspergillus aortitis after cardiac surgery. J Am Coll Cardiol 2003;41:152– 156. 6. Ellis ME, Al-Abdely H, Sandridge A, et al: Fungal endocarditis:evidence in the world literature, 1965–1995. Clin Infect Dis 2001;32:50–62.
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