Case Of the Week #3

Mitral Valve Endocarditis with Fungemia

In this patient who presented to the hospital​ with mild shortness of breath and severe fatigue, the differential is quite broad. The fact that she presented during the COVID19 pandemic of course brings this to the top of the differential. 

Her initial COVID19 nasal swab was negative. However given the sensitivity of the tests are between 71-98%, with a high suspicion it is still reasonable to assume she has COVID19.

Another way to evaluate for COVID19 is to perform lung ultrasound. From China to Italy to the U.S., there are already many studies describing common lung findings in COVID19. They include:
 

  • Abnormalities mostly in posterior and inferior lung areas

  • Thickening of the pleural line with pleural line irregularity

  • B lines in a variety of patterns including focal, multifocal, and confuent 

  • Consolidations in a variety of patterns including multifocal small, non-translobar, and translobar with occasional mobile air bronchograms

  • Pleural effusions are uncommon.

In this patient's lung exam, both anteriorly and posteriorly you can see A-lines, or horizontal lines that are reflections of the pleural line. You may also appreciate that the pleural line has lung sliding and is smooth. She was also found to have a tiny right pleural effusion (not pictured) which further refutes the diagnosis of COVID19. Go here to learn about the lung POCUS exam.

In this patient's cardiac exam, it becomes clear there is a mobile structure on the mitral valve. Highly mobile, round, at least 3cm in size. 12 hours later, she grew candida in her blood.

Given her history of multiple abdominal surgeries, concern for fistula formation and and translocation of yeast to her blood. 

Treatment & Prognosis

Candidal endocarditis is rare (2% of endocarditis), and is a difficult disease to manage and treat. It usually involves many months of combination antifungal therapy with or without surgical removal.

Usually seen in IV drug users, although in this case, multiple abdominal surgeries was a major risk factor. In a case series on 30 patients, 16 had predisposing cardiac disease (prosthetic valves) and 9 were IV drug users. 13 required valve replacement and at 1 year follow up, mortality rate was 38%. 

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