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rates of 30&#8211;40&#37; have been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 50-year-old man with a history of smoking&#44; drug addiction and chronic hepatitis C went to the emergency department with asthenia&#44; fever and headache of one month&#39;s evolution and abdominal pain for two days&#46; On physical examination he presented fever&#59; cardiac auscultation revealed a loud decrescendo diastolic murmur&#44; grade III&#47;VI&#44; at the left sternal border&#59; there were no signs of heart failure&#46; Laboratory tests revealed acute renal failure &#40;creatinine 2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and urea 60<span class="elsevierStyleHsp" style=""></span>mg&#47;dl compared to normal values one week previously&#41;&#44; elevated C-reactive protein &#40;77&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#41; and normocytic normochromic anemia &#40;Hb 11&#46;2<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#41;&#46; Abdominal computed tomography &#40;CT&#41; showed splenomegaly without visible infarcted areas and right hydrouretonephrosis caused by an aneurysm of the right common iliac artery &#40;42<span class="elsevierStyleHsp" style=""></span>mm maximum diameter&#41;&#46; Transthoracic echocardiography &#40;TTE&#41; revealed a 15-mm vegetation on the non-coronary leaflet of the aortic valve &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41; and severe aortic regurgitation &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#44; together with moderate to severe left ventricular systolic dysfunction &#40;ejection fraction 35&#37;&#41;&#59; these findings were confirmed by transesophageal echocardiography&#46; The patient was admitted to the cardiology department&#44; where empirical antibiotic therapy was begun with vancomycin and meropenem&#59; it was decided not to add an aminoglycoside due to his low glomerular filtration rate&#44; estimated at 20<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#46; On the second day of hospital stay he showed signs of cognitive slowing&#44; with no focal neurological alterations&#59; subsequent cerebral magnetic resonance imaging &#40;MRI&#41; showed multiple recent cerebral infarcts&#46; Amphotericin B-susceptible <span class="elsevierStyleItalic">Candida albicans</span> was isolated from blood cultures&#59; antifungal therapy was begun and the surgical center was contacted in order to transfer the patient for aortic valve replacement&#46; While awaiting transfer&#44; he suddenly suffered intense pain&#44; coolness and loss of pulses in his left leg due to acute ischemia&#44; probably caused by cardioembolism from the fungal vegetation&#46; He was transferred urgently to a vascular surgery center where distal left patellofemoral embolectomy was successfully performed&#46; The patient was then transferred to the cardiothoracic center and the aortic valve was replaced by a bioprosthetic valve&#46; Microbiological analysis of the aortic valve and the embolus removed from the left femoral artery revealed <span class="elsevierStyleItalic">C&#46; albicans</span>&#46; Postoperative TTE showed normal aortic prosthetic valve function and after 14 days the patient was transferred to the cardiology department of our hospital&#46; During hospitalization he presented fever and elevated inflammatory markers&#59; repeat TTE confirmed normal prosthetic valve function&#44; with no evidence of vegetations&#46; MRI of the abdomen and lower limbs detected a large pseudoaneurysm of the right iliac artery&#44; the external iliac artery being occluded distal to the pseudoaneurysm&#44; multiple swellings compatible with abscesses in the left groin and thigh &#40;the access site for the previous vascular surgery&#41;&#44; and abscesses in the anterolateral muscle compartment of the left leg &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; In view of the existence of a focus of infection and the absence of evidence of endocarditis on TTE&#44; it was decided not to perform transesophageal echocardiography&#46; The patient was transferred to the vascular surgery department&#44; where he underwent total aneurysmectomy with femoro-femoral crossover bypass using an inverted right greater saphenous vein graft&#44; together with exploration and drainage of the abscesses in the left leg&#46; Microbiological study of the pseudoaneurysm revealed <span class="elsevierStyleItalic">Staphylococcus epidermidis</span>&#46; During hospitalization in the vascular surgery department intermittent fever persisted and the patient&#39;s general condition progressively deteriorated&#46; <span class="elsevierStyleItalic">S&#46; epidermidis</span> was detected in repeat blood cultures and broad-spectrum antibiotic therapy was begun with vancomycin and meropenem&#46; CT of the pelvis and thighs revealed two new pseudoaneurysms&#44; in the left internal iliac artery and the left superficial femoral artery&#46; The patient underwent further surgery&#44; during which it became clear that the clinical situation had progressed rapidly&#44; with rupture of the left femoral pseudoaneurysm and extensive hemorrhagic infiltration and abscesses in the thigh&#46; The left internal iliac and left superficial femoral arteries were ligated and devitalized tissue and purulent collections were thoroughly debrided&#46; Late in the procedure it was decided to proceed to open transfemoral amputation of the leg&#44; due to gangrene&#46; The patient remained in the vascular surgery department for four months&#44; during which antifungal therapy was maintained&#59; transfemoral reamputation was performed and surgical debridement of abscesses in the stump were required on several occasions&#46; After partial closure of the residual limb he was discharged&#44; clinically stable&#59; it was decided not to continue antifungal therapy due to its possible hepatic toxicity and the patient&#39;s chronic hepatitis C&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Four months after discharge&#44; the patient was admitted to the emergency department with fever and abdominal pain&#46; Abdominal CT revealed multiple renal and splenic infarcts and celiac trunk embolization &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46; TTE showed an 8-mm vegetation on the aortic prosthesis and moderate aortic regurgitation&#46; He was transferred to the cardiothoracic surgery department for emergency surgery&#44; but suffered cardiac arrest before reaching the operating room&#46; Blood cultures from the emergency department revealed the presence of <span class="elsevierStyleItalic">C&#46; albicans</span>&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Fungal endocarditis tends to affect relatively young patients&#44; with a mean age of 40 years&#44; although those with prosthetic valve endocarditis may be older&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5</span></a> The characteristic echocardiographic feature is the presence of large vegetations&#44; which carry a high risk for central and peripheral embolization&#46; The most common complications are embolization &#40;which can lead to occlusion of the limb arteries&#41;&#44; neurological alterations and heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Early surgical intervention&#44; immediately after beginning antifungal therapy&#44; is the treatment of choice&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">There is a lack of clear recommendations in the literature concerning the best antifungal therapy&#44; and in particular its duration&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Although rare&#44; fungal infection of prosthetic valves is more common than of native valves&#59; <span class="elsevierStyleItalic">Candida</span> spp&#46; are most often involved&#46; Boland et al&#46;&#44; of the Mayo Clinic&#44; presented a 40-year series of fungal prosthetic valve endocarditis&#44; with 21 cases and mortality of 57&#37;&#46; <span class="elsevierStyleItalic">C&#46; albicans</span> was isolated in most cases&#59; the majority of patients were immunocompetent&#46; The aortic valve was most frequently affected&#44; with 43&#37; of patients presenting endocarditis a year after valve implantation&#46; All patients received antifungal therapy&#44; 95&#37; of them with amphotericin B&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">One of the first prospective studies on endocarditis was by Falcone et al&#46;&#44; an Italian multicenter study including 903 patients&#46; <span class="elsevierStyleItalic">Candida</span> endocarditis was diagnosed in 15 cases&#59; two-thirds were treated with caspofungin alone or in combination with other antifungals&#46; Evidence that amphotericin B fails to penetrate well into clots and vegetations&#44; and hence has lower <span class="elsevierStyleItalic">in vivo</span> activity than predicted by <span class="elsevierStyleItalic">in vitro</span> testing&#44; compared to the greater activity of caspofungin&#44; means that the latter is a more promising antifungal&#46; According to a meta-analysis by Steinbach et al&#46;&#44; this study also showed that whichever antifungal is used&#44; the cornerstone of treatment for fungal endocarditis is early surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">More recently&#44; in a meta-analysis on the role of fluconazole in patients who are not eligible for valve replacement&#44; Smego et al&#46; concluded that fluconazole in isolation is associated with a high rate of recurrence or death &#40;42&#37;&#41; and should therefore not be used alone&#59; however&#44; when used in conjunction with another antifungal it led to clinical improvement in 88&#37; and 68&#37; of patients with fungal endocarditis of native and prosthetic valves&#44; respectively&#46; In this meta-analysis the best results were obtained with chronic suppressive therapy with fluconazole for at least six months&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The 2009 guidelines of the Infectious Diseases Society of America recommend surgical valve replacement in cases of <span class="elsevierStyleItalic">Candida</span> endocarditis in association with antifungal therapy&#44; specifically liposomal amphotericin B &#40;3&#8211;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; with or without flucytosine &#40;25<span class="elsevierStyleHsp" style=""></span>mg&#47;kg 4 times daily&#41;&#44; or amphotericin B deoxycholate &#40;0&#46;6&#8211;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; with or without flucytosine&#44; or an echinocandin &#40;<span class="elsevierStyleItalic">e&#46;g&#46;</span>&#44; caspofungin 50&#8211;150<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#59; treatment should continue for at least six weeks after valve replacement and for longer in patients with perivalvular abscesses or other complications&#46; For patients who cannot undergo valve replacement&#44; long-term suppression with fluconazole at a dosage of 400&#8211;800<span class="elsevierStyleHsp" style=""></span>mg &#40;6&#8211;12<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41; daily is recommended&#46; For prosthetic valve fungal endocarditis&#44; the same recommendations apply&#44; and suppressive therapy should be lifelong if valve replacement is not possible&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In the case presented&#44; it was decided not to prolong antifungal therapy due to the high risk of hepatic toxicity in a patient with known liver disease&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Fungal endocarditis is a rare disease&#44; although its incidence is increasing&#44; with high mortality&#46; Treatment is based on early surgical intervention together with a long course of antifungal therapy&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 50-year-old man with a history of drug addiction was admitted to the cardiology department for aortic valve fungal endocarditis complicated by severe aortic regurgitation&#44; cerebral infarcts and right common iliac artery pseudoaneurysm&#46; While awaiting transfer to the cardiothoracic surgery department&#44; the patient presented acute arterial ischemia of the left leg&#44; and distal left patellofemoral embolectomy was successfully performed&#46; The patient was then transferred to the cardiothoracic center and the aortic valve was replaced by a bioprosthetic valve&#46; After 14 days he was referred for vascular surgery&#44; where the four-month hospitalization was complicated by left leg amputation&#46; Four months after discharge&#44; the patient was admitted to the emergency department for recurrent fungal endocarditis complicated by multiple renal and splenic infarcts and celiac trunk embolization&#46; He was transferred to the cardiothoracic surgery department&#44; but suffered cardiac arrest before surgical intervention&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Doente do g&#233;nero masculino&#44; de 50 anos de idade&#44; ex-toxicodependente&#44; admitido no servi&#231;o de Cardiologia por endocardite f&#250;ngica da v&#225;lvula a&#243;rtica complicada de insufici&#234;ncia a&#243;rtica severa&#44; enfartes cerebrais e pseudoaneurisma da art&#233;ria il&#237;aca comum direita&#46; Enquanto aguardava transfer&#234;ncia para o servi&#231;o de cirurgia cardiotor&#225;cica&#44; o doente apresentou isquemia arterial aguda do membro inferior esquerdo&#44; tendo realizado tromboembolectomia femuro-distal esquerda&#46; Posteriormente&#44; foi submetido &#224; substitui&#231;&#227;o da v&#225;lvula a&#243;rtica por pr&#243;tese biol&#243;gica&#46; Ap&#243;s catorze dias de internamento foi internado no servi&#231;o de Cirurgia Vascular&#44; tendo o internamento de 4 meses sido complicado com amputa&#231;&#227;o da perna esquerda&#46; Quatro meses ap&#243;s a alta&#44; o doente recorreu ao servi&#231;o de urg&#234;ncia por febre e dor abdominal&#46; Foi-lhe diagnosticada recorr&#234;ncia de endocardite f&#250;ngica complicada por enfartes espl&#233;nicos e renais e &#234;mbolo no tronco cel&#237;aco&#46; O doente foi transferido de urg&#234;ncia para o servi&#231;o de Cirurgia Cardiotor&#225;cica&#46; Antes da interven&#231;&#227;o cir&#250;rgica apresentou paragem cardiorrespirat&#243;ria&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Ribeiro&#44; S&#44; et al&#46; Endocardite f&#250;ngica com emboliza&#231;&#227;o central e perif&#233;rica&#58; um caso cl&#237;nico&#46; Rev Port Cardiol&#46; 2012&#46; <span class="elsevierStyleInterRef" href="doi:10.1016/j.repc.2011.12.019">doi&#58;10&#46;1016&#47;j&#46;repc&#46;2011&#46;12&#46;019</span>&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiogram&#44; apical 5-chamber view&#44; showing vegetation on the aortic valve &#40;arrow&#41;&#46; AE&#58; left atrium&#59; VE&#58; left ventricle&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">MRI angiogram showing pseudoaneurysm of the right iliac artery &#40;solid arrow&#41; and abscess of the left leg &#40;open arrow&#41;&#46;</p>"
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Case report
Fungal endocarditis with central and peripheral embolization: Case report
Endocardite fúngica com embolização central e periférica: um caso clínico
Sílvia Ribeiroa,
Corresponding author
silviamartinsribeiro@gmail.com

Corresponding author.
, António Gaspara, António Assunçãob, José Pinheiro Torresc, Pedro Azevedoa, Luís Bastoa, Paulo Pinhoc, Adelino Correiaa
a Serviço de Cardiologia, Hospital de Braga, Braga, Portugal
b Serviço de Cirurgia Vascular, Hospital de Braga, Braga, Portugal
c Serviço de Cirurgia Cardiotorácica, Hospital de São João, Porto, Portugal
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiogram&#44; apical 5-chamber view&#44; showing vegetation on the aortic valve &#40;arrow&#41;&#46; AE&#58; left atrium&#59; VE&#58; left ventricle&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Fungal endocarditis is a rare entity with high mortality even with combined medical and surgical treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> Risk factors include previous valve surgery and antibiotic therapy&#44; intravenous drug use&#44; intravascular catheter placement and immunosuppression&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a><span class="elsevierStyleItalic">Candida</span> spp&#46; are the most frequent etiological agents&#46; Early surgical intervention immediately after initiation of antifungal therapy&#44; particularly amphotericin B&#44; is the treatment of choice&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a> Recurrence is common&#59; rates of 30&#8211;40&#37; have been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 50-year-old man with a history of smoking&#44; drug addiction and chronic hepatitis C went to the emergency department with asthenia&#44; fever and headache of one month&#39;s evolution and abdominal pain for two days&#46; On physical examination he presented fever&#59; cardiac auscultation revealed a loud decrescendo diastolic murmur&#44; grade III&#47;VI&#44; at the left sternal border&#59; there were no signs of heart failure&#46; Laboratory tests revealed acute renal failure &#40;creatinine 2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and urea 60<span class="elsevierStyleHsp" style=""></span>mg&#47;dl compared to normal values one week previously&#41;&#44; elevated C-reactive protein &#40;77&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#41; and normocytic normochromic anemia &#40;Hb 11&#46;2<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#41;&#46; Abdominal computed tomography &#40;CT&#41; showed splenomegaly without visible infarcted areas and right hydrouretonephrosis caused by an aneurysm of the right common iliac artery &#40;42<span class="elsevierStyleHsp" style=""></span>mm maximum diameter&#41;&#46; Transthoracic echocardiography &#40;TTE&#41; revealed a 15-mm vegetation on the non-coronary leaflet of the aortic valve &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41; and severe aortic regurgitation &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#44; together with moderate to severe left ventricular systolic dysfunction &#40;ejection fraction 35&#37;&#41;&#59; these findings were confirmed by transesophageal echocardiography&#46; The patient was admitted to the cardiology department&#44; where empirical antibiotic therapy was begun with vancomycin and meropenem&#59; it was decided not to add an aminoglycoside due to his low glomerular filtration rate&#44; estimated at 20<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#46; On the second day of hospital stay he showed signs of cognitive slowing&#44; with no focal neurological alterations&#59; subsequent cerebral magnetic resonance imaging &#40;MRI&#41; showed multiple recent cerebral infarcts&#46; Amphotericin B-susceptible <span class="elsevierStyleItalic">Candida albicans</span> was isolated from blood cultures&#59; antifungal therapy was begun and the surgical center was contacted in order to transfer the patient for aortic valve replacement&#46; While awaiting transfer&#44; he suddenly suffered intense pain&#44; coolness and loss of pulses in his left leg due to acute ischemia&#44; probably caused by cardioembolism from the fungal vegetation&#46; He was transferred urgently to a vascular surgery center where distal left patellofemoral embolectomy was successfully performed&#46; The patient was then transferred to the cardiothoracic center and the aortic valve was replaced by a bioprosthetic valve&#46; Microbiological analysis of the aortic valve and the embolus removed from the left femoral artery revealed <span class="elsevierStyleItalic">C&#46; albicans</span>&#46; Postoperative TTE showed normal aortic prosthetic valve function and after 14 days the patient was transferred to the cardiology department of our hospital&#46; During hospitalization he presented fever and elevated inflammatory markers&#59; repeat TTE confirmed normal prosthetic valve function&#44; with no evidence of vegetations&#46; MRI of the abdomen and lower limbs detected a large pseudoaneurysm of the right iliac artery&#44; the external iliac artery being occluded distal to the pseudoaneurysm&#44; multiple swellings compatible with abscesses in the left groin and thigh &#40;the access site for the previous vascular surgery&#41;&#44; and abscesses in the anterolateral muscle compartment of the left leg &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; In view of the existence of a focus of infection and the absence of evidence of endocarditis on TTE&#44; it was decided not to perform transesophageal echocardiography&#46; The patient was transferred to the vascular surgery department&#44; where he underwent total aneurysmectomy with femoro-femoral crossover bypass using an inverted right greater saphenous vein graft&#44; together with exploration and drainage of the abscesses in the left leg&#46; Microbiological study of the pseudoaneurysm revealed <span class="elsevierStyleItalic">Staphylococcus epidermidis</span>&#46; During hospitalization in the vascular surgery department intermittent fever persisted and the patient&#39;s general condition progressively deteriorated&#46; <span class="elsevierStyleItalic">S&#46; epidermidis</span> was detected in repeat blood cultures and broad-spectrum antibiotic therapy was begun with vancomycin and meropenem&#46; CT of the pelvis and thighs revealed two new pseudoaneurysms&#44; in the left internal iliac artery and the left superficial femoral artery&#46; The patient underwent further surgery&#44; during which it became clear that the clinical situation had progressed rapidly&#44; with rupture of the left femoral pseudoaneurysm and extensive hemorrhagic infiltration and abscesses in the thigh&#46; The left internal iliac and left superficial femoral arteries were ligated and devitalized tissue and purulent collections were thoroughly debrided&#46; Late in the procedure it was decided to proceed to open transfemoral amputation of the leg&#44; due to gangrene&#46; The patient remained in the vascular surgery department for four months&#44; during which antifungal therapy was maintained&#59; transfemoral reamputation was performed and surgical debridement of abscesses in the stump were required on several occasions&#46; After partial closure of the residual limb he was discharged&#44; clinically stable&#59; it was decided not to continue antifungal therapy due to its possible hepatic toxicity and the patient&#39;s chronic hepatitis C&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Four months after discharge&#44; the patient was admitted to the emergency department with fever and abdominal pain&#46; Abdominal CT revealed multiple renal and splenic infarcts and celiac trunk embolization &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46; TTE showed an 8-mm vegetation on the aortic prosthesis and moderate aortic regurgitation&#46; He was transferred to the cardiothoracic surgery department for emergency surgery&#44; but suffered cardiac arrest before reaching the operating room&#46; Blood cultures from the emergency department revealed the presence of <span class="elsevierStyleItalic">C&#46; albicans</span>&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Fungal endocarditis tends to affect relatively young patients&#44; with a mean age of 40 years&#44; although those with prosthetic valve endocarditis may be older&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5</span></a> The characteristic echocardiographic feature is the presence of large vegetations&#44; which carry a high risk for central and peripheral embolization&#46; The most common complications are embolization &#40;which can lead to occlusion of the limb arteries&#41;&#44; neurological alterations and heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Early surgical intervention&#44; immediately after beginning antifungal therapy&#44; is the treatment of choice&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">There is a lack of clear recommendations in the literature concerning the best antifungal therapy&#44; and in particular its duration&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Although rare&#44; fungal infection of prosthetic valves is more common than of native valves&#59; <span class="elsevierStyleItalic">Candida</span> spp&#46; are most often involved&#46; Boland et al&#46;&#44; of the Mayo Clinic&#44; presented a 40-year series of fungal prosthetic valve endocarditis&#44; with 21 cases and mortality of 57&#37;&#46; <span class="elsevierStyleItalic">C&#46; albicans</span> was isolated in most cases&#59; the majority of patients were immunocompetent&#46; The aortic valve was most frequently affected&#44; with 43&#37; of patients presenting endocarditis a year after valve implantation&#46; All patients received antifungal therapy&#44; 95&#37; of them with amphotericin B&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">One of the first prospective studies on endocarditis was by Falcone et al&#46;&#44; an Italian multicenter study including 903 patients&#46; <span class="elsevierStyleItalic">Candida</span> endocarditis was diagnosed in 15 cases&#59; two-thirds were treated with caspofungin alone or in combination with other antifungals&#46; Evidence that amphotericin B fails to penetrate well into clots and vegetations&#44; and hence has lower <span class="elsevierStyleItalic">in vivo</span> activity than predicted by <span class="elsevierStyleItalic">in vitro</span> testing&#44; compared to the greater activity of caspofungin&#44; means that the latter is a more promising antifungal&#46; According to a meta-analysis by Steinbach et al&#46;&#44; this study also showed that whichever antifungal is used&#44; the cornerstone of treatment for fungal endocarditis is early surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">More recently&#44; in a meta-analysis on the role of fluconazole in patients who are not eligible for valve replacement&#44; Smego et al&#46; concluded that fluconazole in isolation is associated with a high rate of recurrence or death &#40;42&#37;&#41; and should therefore not be used alone&#59; however&#44; when used in conjunction with another antifungal it led to clinical improvement in 88&#37; and 68&#37; of patients with fungal endocarditis of native and prosthetic valves&#44; respectively&#46; In this meta-analysis the best results were obtained with chronic suppressive therapy with fluconazole for at least six months&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The 2009 guidelines of the Infectious Diseases Society of America recommend surgical valve replacement in cases of <span class="elsevierStyleItalic">Candida</span> endocarditis in association with antifungal therapy&#44; specifically liposomal amphotericin B &#40;3&#8211;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; with or without flucytosine &#40;25<span class="elsevierStyleHsp" style=""></span>mg&#47;kg 4 times daily&#41;&#44; or amphotericin B deoxycholate &#40;0&#46;6&#8211;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; with or without flucytosine&#44; or an echinocandin &#40;<span class="elsevierStyleItalic">e&#46;g&#46;</span>&#44; caspofungin 50&#8211;150<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#59; treatment should continue for at least six weeks after valve replacement and for longer in patients with perivalvular abscesses or other complications&#46; For patients who cannot undergo valve replacement&#44; long-term suppression with fluconazole at a dosage of 400&#8211;800<span class="elsevierStyleHsp" style=""></span>mg &#40;6&#8211;12<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41; daily is recommended&#46; For prosthetic valve fungal endocarditis&#44; the same recommendations apply&#44; and suppressive therapy should be lifelong if valve replacement is not possible&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In the case presented&#44; it was decided not to prolong antifungal therapy due to the high risk of hepatic toxicity in a patient with known liver disease&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Fungal endocarditis is a rare disease&#44; although its incidence is increasing&#44; with high mortality&#46; Treatment is based on early surgical intervention together with a long course of antifungal therapy&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 50-year-old man with a history of drug addiction was admitted to the cardiology department for aortic valve fungal endocarditis complicated by severe aortic regurgitation&#44; cerebral infarcts and right common iliac artery pseudoaneurysm&#46; While awaiting transfer to the cardiothoracic surgery department&#44; the patient presented acute arterial ischemia of the left leg&#44; and distal left patellofemoral embolectomy was successfully performed&#46; The patient was then transferred to the cardiothoracic center and the aortic valve was replaced by a bioprosthetic valve&#46; After 14 days he was referred for vascular surgery&#44; where the four-month hospitalization was complicated by left leg amputation&#46; Four months after discharge&#44; the patient was admitted to the emergency department for recurrent fungal endocarditis complicated by multiple renal and splenic infarcts and celiac trunk embolization&#46; He was transferred to the cardiothoracic surgery department&#44; but suffered cardiac arrest before surgical intervention&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Doente do g&#233;nero masculino&#44; de 50 anos de idade&#44; ex-toxicodependente&#44; admitido no servi&#231;o de Cardiologia por endocardite f&#250;ngica da v&#225;lvula a&#243;rtica complicada de insufici&#234;ncia a&#243;rtica severa&#44; enfartes cerebrais e pseudoaneurisma da art&#233;ria il&#237;aca comum direita&#46; Enquanto aguardava transfer&#234;ncia para o servi&#231;o de cirurgia cardiotor&#225;cica&#44; o doente apresentou isquemia arterial aguda do membro inferior esquerdo&#44; tendo realizado tromboembolectomia femuro-distal esquerda&#46; Posteriormente&#44; foi submetido &#224; substitui&#231;&#227;o da v&#225;lvula a&#243;rtica por pr&#243;tese biol&#243;gica&#46; Ap&#243;s catorze dias de internamento foi internado no servi&#231;o de Cirurgia Vascular&#44; tendo o internamento de 4 meses sido complicado com amputa&#231;&#227;o da perna esquerda&#46; Quatro meses ap&#243;s a alta&#44; o doente recorreu ao servi&#231;o de urg&#234;ncia por febre e dor abdominal&#46; Foi-lhe diagnosticada recorr&#234;ncia de endocardite f&#250;ngica complicada por enfartes espl&#233;nicos e renais e &#234;mbolo no tronco cel&#237;aco&#46; O doente foi transferido de urg&#234;ncia para o servi&#231;o de Cirurgia Cardiotor&#225;cica&#46; Antes da interven&#231;&#227;o cir&#250;rgica apresentou paragem cardiorrespirat&#243;ria&#46;</p>"
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