Challenging differential diagnosis
Neal Dixit, Evelyn S. Escobedo, Ramin Ebrahimi
Department of Internal Medicine, University of California Los Angeles (UCLA) Medical Center, Los Angeles, CA, USA
Am J Case Rep 2020; 21:e926206
Available online: 2020-08-28
The management of fungal endocarditis is difficult due to high mortality and incidence of embolization. Fungal blood cultures are the criterion standard for diagnosis but show slow growth or remain negative in more than 50% of cases. We present a case in which the 1,3-ß-D-glucan (BG) assay was used to initiate antifungal treatment prior to growth in blood culture.
CASE REPORT: A 45-year-old man with known intravenous drug use presented to the Emergency Department in acute hypoxemic respiratory failure with a prominent aortic regurgitation murmur. Imaging findings were suggestive of endocarditis. In the Intensive Care Unit, investigations confirmed aortic valve infective endocarditis with abscess. Evidence of widespread embolization, including a shin abscess positive for Candida albicans combined with a positive BG assay prompted treatment with antifungal medication prior to positive fungal cultures. The patient underwent valve replacement and during recovery was incidentally found to have subclinical cerebral infarctions caused by a septic thrombus positive for C. albicans in the right carotid artery despite weeks of antifungal treatment. Carotid endarterectomy successfully removed the thrombus, but the patient developed a right-sided stroke. Four months later, the patient has no evidence of aortic insufficiency on echocardiogram and has made a nearly full recovery from the stroke.
CONCLUSIONS: We report a case of left-sided fungal endocarditis in which the BG assay was used for timely medical and surgical management leading to a successful cardiac outcome. Stroke from septic emboli is a potential complication even after weeks of antifungal therapy and valvular replacement.
Keywords: beta-Glucans, Early Diagnosis, Endocarditis, Stroke