This article has Open Peer Review reports available.
A rare case of Candida parapsilosis endocarditis in a young healthy woman – case report
© Pelemiš et al.; licensee BioMed Central Ltd. 2013
Received: 14 November 2012
Accepted: 19 February 2013
Published: 22 February 2013
Disseminated fungal infections are still rare conditions, mostly caused by Candida spp. during immunosuppression. Infection of immunocompetent individuals is uncommon. Endocarditis is a rare manifestation during candidaemia, mostly in patients with prosthetic valves. Affection of previously unaltered valves is uncommon.
We presented a case of a young, previously healthy female patient with endocarditis, caused by Candida parapsilosis. The initial symptom, fever, was present four months before hospital admittance. She was febrile without other symptoms and during observation in a local hospital. After her condition deteriorated, she was transferred to the Institute for infectious and tropical diseases, Belgrade. Clinical findings on admission include petechial skin rash and moderate hepatosplenomegaly. Newly developed systolic murmur was noted, and Candida parapsilosis was isolated in multiple blood cultures. Echocardiography revealed 15 × 14 mm vegetations on the right aortic vellum.
She was treated with antifungal drugs (fluconasole, liposomal amphotericin B), and the affected valve was successfully replaced. The same strain of Candida parapsilosis was isolated from the intraoperative material of the valve.
There were no markers of immunosuppression or other conditions which could affect the immune system.
After a prolonged period of treatment she was successfully cured, and she received a long-term intermittent suppressive fluconasole therapy for the time being.
Although disseminated fungal infections are more common today than before, they still remain rare conditions, mostly caused by Candida spp. Candida parapsilosis and Candida tropicalis are the most common causes in Europe [1, 2]. Risk factors include immunosuppression (HIV, neutropenia, transplants, solid tumors), but infection of immunocompetent individuals is uncommon [1, 3]. Candidaemia has a significant mortality rate, up to 44% [1, 2].
Endocarditis is present in 5-25% of patients with candidaemia, mostly in patients with prosthetic valves [4, 5]. Affection of previously unaltered heart valves is uncommon. During the past 20 years, there have been only three cases reported in Sweden . Other authors also refer to Candida endocarditis as an extremely rare occurrence in patients with normal native cardiac valves [6, 7].
We will present a case report of a previously healthy twenty-three year old Caucasian female patient, from a higher social-culture level, living in Belgrade suburbs. She had a negative history data to preexisting diseases, drug use or any underlining conditions.
Laboratory results during course of illness, and follow-up
Day 30 (preoperatively)
Day 40 (8 days after operation)
After 3 year follow-up
Further conservative antifungal therapy was administered after operation, until laboratory findings were normalized, five months later. During this period the patient was treated with liposomal amphotericin B for 36 days, IV in the daily dose of 50 mg. For the rest of the period she was treated with fluconazole IV 200 mg in the dose intervals of 12 hours (approximately four months). During the whole period, no side-effects were observed.
During the 3 year follow-up, there were no other pathological developments, and the patient has been physically active and working.
This report presents a rare disease progress in a young and previously healthy person, without any predisposing conditions - no immunodeficiency or previous valve defect [4–6]. In spite of intensive systemic antifungal therapy, which is recommended [2, 4, 5] there was no improvement, so the operative valve replacement was necessary, which has also been reported in other cases [4–7].
After the patient was discharged from the hospital, she received a long-term intermittent suppressive fluconasole therapy. There is some difference in opinion concerning the time length of this therapy, including possibility of life-long treatment [5, 8, 9]. During the three year follow-up, our patient has been taking 200 mg of fluconasole twice a week with complete recovery and no other physical complaints.
Although rare, Candida endocarditis in previously healthy patients, with no clear risk factors, is possible. During blood cultivation, one should always look for fungus. Candida endocarditis therapy is a combination of antifungal drugs and surgery, and the use of drugs is long-lasting.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The Authors wish to acknowledge Milica Jovanovic MD, PhD, microbiologist, who did an excellent job of identifying the causative agent.
- Marchetti O, Bille J, Fluckiger U, Eggiman P, Ruef C, Garbino J, Calandra T, Glausser MP, Tauber MG, Pittet D: Epidemiology of candidemia in Swiss tertiary care hospitals: secular trends, 1991-2000. Clin Infect Dis. 2004, 38: 311-320. 10.1086/380637.View ArticlePubMedGoogle Scholar
- Pfaller MA, Diekema DJ, Jones RN, Sader HS, Fluit AC, Hollis RJ, Messer SA, and SENTRY Participant Group: International surveillance of bloodstream infections due to Candida species: frequency of occurrence and in vitro susceptibilities to fluconazole, ravuconazole, and voriconazole of isolates collected from 1997 through 1999 in the SENTRY Antimicrobial Surveillance Program. J Clin Microbiol. 2001, 39: 3254-3259. 10.1128/JCM.39.9.3254-3259.2001.View ArticlePubMedPubMed CentralGoogle Scholar
- Almirante B, Rodríguez D, Park BJ: Epidemiology and Predictors of Mortality in Cases of Candida Bloodstream Infection: Results from Population-Based Surveillance, Barcelona, Spain, from 2002 to 2003. J Clin Microbiol. 2005, 43 (4): 1829-1835. 10.1128/JCM.43.4.1829-1835.2005.View ArticlePubMedPubMed CentralGoogle Scholar
- Hogevik H, Alestig K: Fungal endocarditis – a report on seven cases and a brief review. Infection. 1996, 24: 17-21. 10.1007/BF01780644.View ArticlePubMedGoogle Scholar
- Branco L, Pitta ML, Bernardes L: A review of infectious endocarditis due to Candida [Abstract]. Rev Port Cardiol. 1997, 16: 967-974.PubMedGoogle Scholar
- Gullu AU, Akcar M, Arnaz A: Candida parapsilosis tricuspid native valve endocarditis: 3-year follow-up after surgical treatment. Interact Cardiovasc Thorac Surg. 2008, 7: 513-514. 10.1510/icvts.2007.173435.View ArticlePubMedGoogle Scholar
- Kan CD, Luo CY, Lin PY: Native-valve endocarditis due to Candida parapsilosis. Interact Cardiovasc Thorac Surg. 2002, 1: 66-68. 10.1016/S1569-9293(02)00017-8.View ArticlePubMedGoogle Scholar
- Zedtwitz-Liebenstein K, Gabriel H, Willinger B: Prosthetic valve endocarditis due to Candida tropicalis complicated by multiple pseudoaneurysms. Infection. 2001, 29: 177-179. 10.1007/s15010-001-9170-9.View ArticlePubMedGoogle Scholar
- Chim CS, Ho PL, Yuen ST, Yuen KY: Fungal endocarditis in bone marrow transplantation: case report and review of literature. J Infect. 1998, 37: 287-291. 10.1016/S0163-4453(98)92169-7.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.