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valve replacement and long-term eradication therapy&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 38-year-old woman with a history of surgically corrected tetralogy of Fallot at the age of 11&#44; and recent dental procedures&#44; presented with fever&#44; anorexia&#44; weight loss and fatigue for one month and epigastric pain of recent onset&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">On physical examination the patient was pale and presented with bilateral lower limb edema&#44; jugular distension and a grade II&#47;IV diastolic murmur on the left sternal border&#46; Laboratory tests showed elevated C-reactive protein &#40;CRP&#41;&#44; anemia and thrombocytopenia&#46; Blood cultures were negative&#46; Abdominal computed tomography &#40;CT&#41; revealed hepatomegaly and splenomegaly with splenic infarct&#44; thought to result from septic embolism&#46; The transthoracic echocardiogram &#40;TTE&#41; revealed an extremely mobile 15-mm vegetation on the right coronary cusp of the aortic valve and severe aortic regurgitation&#44; accompanying previously known severe dilation of the right heart chambers and pulmonary regurgitation&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A diagnosis of infective endocarditis was made and empirical antibiotic therapy was initiated with amoxicillin-clavulanate and gentamicin&#44; prior to transfer to our hospital&#46; After 17 days of antibiotic therapy&#44; signs of congestive heart failure and infection persisted and the patient was referred to our cardiothoracic surgery center&#46; Replacement of the aortic and pulmonary valves with 23- and 25-mm Carpentier-Edwards Perimount Magna<span class="elsevierStyleSup">&#174;</span> bioprostheses&#44; respectively&#44; reconstruction of the right ventricular outflow tract&#44; and tricuspid valve ring annuloplasty were successfully performed&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In the postoperative period&#44; the patient presented with nonoliguric acute renal failure and continuous renal replacement therapy &#40;catheter-based hemodialysis&#41; was instituted&#46; The patient was discharged 53 days after admission on a hemodialysis program and with no evidence of prosthetic infection on TTE&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Three days after discharge she was readmitted with fever and dyspnea&#44; along with elevated CRP and anemia&#46; Blood cultures were positive for <span class="elsevierStyleItalic">C&#46; albicans</span>&#46; Antifungal therapy with liposomal amphotericin B was initiated but subsequent blood cultures remained positive&#46; A transesophageal echocardiogram &#40;TEE&#41; demonstrated large vegetations on the aortic valve and a periprosthetic leak resulting in mild aortic regurgitation&#44; establishing the diagnosis of FE &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">At redo surgery the pulmonary prosthesis was also found to contain large vegetations &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41; and both prosthetic valves were replaced by cryopreserved homografts&#46; Microbiological analysis of the removed tissue revealed <span class="elsevierStyleItalic">C&#46; albicans</span>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">In the postoperative period blood cultures became negative and renal function recovered&#46; Due to pancytopenia&#44; liposomal amphotericin B therapy was switched to intravenous fluconazole&#46; Five days after surgery&#44; the patient suffered acute ischemia of the right lower limb and right iliofemoral embolectomy was performed by vascular surgery&#46; Direct examination of the thrombus revealed <span class="elsevierStyleItalic">C&#46; albicans</span> hyphae&#46; TTE and cardiac magnetic resonance imaging showed no signs of cardiac infection&#46; Thoracoabdominal CT revealed a pseudoaneurysm of the right iliac artery &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#44; the probable source of the emboli&#44; and the patient was reoperated&#44; with resection of the aneurysm and replacement by a segment of reversed saphenous vein&#46; Clinical pathological analysis confirmed its infectious etiology and the diagnosis of mycotic aneurysm&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The patient&#39;s condition improved and she was discharged eight weeks after the second cardiac surgery&#44; on suppressive antifungal therapy with oral fluconazole and surveillance by imaging studies and blood cultures&#46; Expected time of treatment will be at least a year&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Prosthetic valve endocarditis &#40;PVE&#41; is the most severe form of infective endocarditis&#44; accounting for 10-30&#37; of all cases&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> Health care-associated infections have been found to account for 37&#37; of PVE&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a> The risk is higher in the first year after valve replacement surgery for both mechanical and bioprosthetic valves&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Fungal etiology accounts for 2-4&#37; of all cases of endocarditis&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> Its incidence has increased in recent decades due to a growing number of patients at risk&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> It is associated with worse prognosis<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> and 50&#37; mortality rate despite treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">PVE is a diagnostic challenge&#58; the modified Duke criteria<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a> lack sensitivity in this context&#44; blood cultures are more often negative and echocardiography has less diagnostic accuracy&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> Therefore&#44; a high index of suspicion is needed for its diagnosis&#44; in order to enable early initiation of therapeutic measures that can improve the prognosis&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In the case reported&#44; no vegetations were identified in the pulmonary prosthesis by echocardiography&#46; This is presumably due to the poor visualization of the pulmonary prosthesis by TEE and to its lower sensitivity in cases of PVE&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">TEE is more sensitive and useful in cases of PVE&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a> FE usually leads to larger vegetations than those found in bacterial endocarditis&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a> As a result&#44; arterial embolization&#44; as presented by our patient&#44; is more common&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a> the usual sites being the cerebral circulation&#44; extremities and gastrointestinal tract&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">No randomized studies have assessed the optimal therapy for fungal PVE&#46; The therapeutic approach is based on antifungal agents and valve replacement surgery&#44; although successful treatments of FE have been reported with medical therapy alone&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> Moreover&#44; no uniform recommendations are available concerning the most appropriate antimicrobial regimen&#44; the ideal timing for surgery or the total duration of treatment&#46; According to the ESC guidelines&#44; surgery may be undertaken on an elective or urgent basis depending on the patient&#39;s condition&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> although others recommend earlier surgery&#44; as it appears to improve outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a> In the case presented&#44; an initial approach with antifungal therapy was adopted&#44; due to the high risk associated with a third cardiac surgery &#40;EuroSCORE II of 38&#46;5&#41;&#44; but the persistent fungemia made surgery advisable&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In our patient&#44; amphotericin B was used in a lipid formulation to avoid further deterioration of renal function&#44; but the development of pancytopenia forced conversion to fluconazole&#46; Since the potential for recurrent infection is extremely high in fungal PVE&#44; suppressive therapy with fluconazole is recommended for prolonged periods or even indefinitely&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Given the high recurrence rate of FE&#44; the use of homografts is justified by their higher resistance to recurrent infection&#46; This advantage may be explained by the suggestion that homografts have the ability to reproduce collagen&#44; improving postoperative local healing&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> Homografts allow complete debridement of all infected tissue and better tissue penetration of antimicrobial agents&#44; facilitating eradication of the infection&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The source of our patient&#39;s candidemia is unclear&#44; but the long hospitalization&#44; the presence of a recent implanted prosthetic valve&#44; and an indwelling central venous catheter for the hemodialysis program represent risk factors that may explain it&#46; The patient&#39;s congenital heart disease is also a predisposing factor for infective endocarditis&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In this case numerous predictors of poor outcome were present&#44; besides the fungal etiology of a prosthetic valve infection&#46; These included the clinical manifestations of congestive heart failure&#44; the long period of hospitalization with central venous catheters&#44; renal failure requiring hemodialysis&#44; the large size of the fungal vegetations&#44; carrying higher embolic risk&#44; and finally the mycotic pseudoaneurysm of the right iliac artery&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0100" class="elsevierStylePara elsevierViewall">FE caused by <span class="elsevierStyleItalic">C&#46; albicans</span> is a rare condition with poor prognosis&#46; The presence of a prosthetic valve and a central venous catheter are major risk factors for FE&#46; The diagnosis is challenging as only about half of blood cultures are positive and the sensitivity of echocardiography in prosthetic valve endocarditis is limited&#46; Despite the lack of evidence from randomized clinical trials&#44; treatment combining antifungal therapy and valve replacement is thought to offer improved clinical outcomes&#46; The timing of surgery is not consensual but early surgery appears to improve survival&#44; depending on the patient&#39;s clinical condition&#46; Moreover&#44; given the high recurrence rate of fungal PVE&#44; homografts appear to be the most appropriate choice&#44; providing the highest resistance to recurrent infection&#44; by allowing complete debridement of infected tissue with low risk of valve dehiscence and better antibiotic penetration&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            2 => "<span class="elsevierStyleItalic">Candida albicans</span>"
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            2 => "<span class="elsevierStyleItalic">Candida albicans</span>"
            3 => "Homoenxertos"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Fungal prosthetic valve endocarditis is an extremely severe form of infective endocarditis&#44; with poor prognosis and high mortality despite treatment&#46; <span class="elsevierStyleItalic">Candida albicans</span> is the most common etiological agent for this rare but increasingly frequent condition&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We present a case of fungal prosthetic valve endocarditis due to <span class="elsevierStyleItalic">C&#46; albicans</span> following aortic and pulmonary valve replacement in a 38-year-old woman with a history of surgically corrected tetralogy of Fallot&#44; prior infective endocarditis and acute renal failure with need for catheter-based hemodialysis&#46; Antifungal therapy with liposomal amphotericin B was initiated prior to cardiac surgery&#44; in which the bioprostheses were replaced by homografts&#44; providing greater resistance to recurrent infection&#46; During hospitalization&#44; a mycotic aneurysm was diagnosed following an episode of acute arterial ischemia&#44; requiring two vascular surgical interventions&#46; Despite the complications&#44; the patient&#39;s outcome was good and she was discharged on suppressive antifungal therapy with oral fluconazole for at least a year&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The reported case illustrates multiple risk factors for fungal endocarditis&#44; as well as complications and predictors of poor prognosis&#44; demonstrating its complexity&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A endocardite f&#250;ngica de pr&#243;tese valvular &#233; uma forma extremamente severa de endocardite infeciosa&#44; com mau progn&#243;stico e elevada mortalidade apesar do tratamento m&#233;dico&#46; <span class="elsevierStyleItalic">Candida albicans</span> &#233; o agente etiol&#243;gico mais frequentemente implicado nesta rara&#44; embora crescente&#44; patologia&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Relata-se um caso de endocardite f&#250;ngica de pr&#243;tese valvular ap&#243;s substitui&#231;&#227;o das v&#225;lvulas a&#243;rtica e pulmonar numa mulher de 38 anos com antecedentes de tetralogia de Fallot cirurgicamente corrigida&#44; endocardite infeciosa pr&#233;via e insufici&#234;ncia renal aguda com necessidade de hemodi&#225;lise por cat&#233;ter&#46; A terap&#234;utica antif&#250;ngica com anfotericina B liposs&#243;mica foi iniciada previamente &#224; cirurgia card&#237;aca&#44; onde as biopr&#243;teses foram substitu&#237;das por homoenxertos&#44; conferindo maior resist&#234;ncia &#224; infe&#231;&#227;o recorrente&#46; Durante o internamento&#44; foi diagnosticado um aneurisma mic&#243;tico&#44; na sequ&#234;ncia de um epis&#243;dio de isquemia arterial aguda&#44; obrigando a duas interven&#231;&#245;es pela Cirurgia Vascular&#46; Apesar das complica&#231;&#245;es&#44; a doente teve um bom <span class="elsevierStyleItalic">outcome</span> cl&#237;nico e recebeu alta com terap&#234;utica de erradica&#231;&#227;o com fluconazol durante&#44; pelo menos&#44; um ano&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">O caso relatado enumera m&#250;ltiplos fatores de risco para endocardite f&#250;ngica&#44; assim como complica&#231;&#245;es e preditores de mau progn&#243;stico&#44; ilustrando a sua complexidade&#46;</p></span>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram&#44; long-axis aortic valve plane&#44; demonstrating the presence of a vegetation in the aortic prosthesis &#40;arrow&#41;&#46; Ao&#58; ascending aorta&#59; LA&#58; left atrium&#59; LV&#58; left ventricle&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Intraoperative photographs&#58; &#40;A&#41; vegetation in the pulmonary valve &#40;arrow&#41;&#59; &#40;B&#41;&#58; infected pulmonary prosthesis&#59; &#40;C&#41; vegetation in the aortic bioprosthesis &#40;arrow&#41;&#46;</p>"
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      "seccion" => array:1 [
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                      ]
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/eurheartj/ehp285"
                      "Revista" => array:6 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fungal endocarditis&#58; evidence in the world literature&#44; 1965-1995"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            0 => "M&#46;E&#46; Ellis"
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              ]
            ]
            2 => array:3 [
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              "referencia" => array:1 [
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                  "contribucion" => array:1 [
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                      "titulo" => "Candida infective endocarditis"
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Case report
Fungal prosthetic valve endocarditis with mycotic aneurysm: Case report
Endocardite fúngica de prótese valvular com aneurisma micótico: caso clínico
Mariana Brandãoa,
Corresponding author
marianabrandao1993@gmail.com

Corresponding author.
, Jorge Almeidab, Rita Ferrazc, Lurdes Santosc, Paulo Pinhob, Jorge Casanovab
a Escola de Ciências da Saúde, Universidade do Minho, Braga, Portugal
b Centro de Cirurgia Cardiotorácica, Hospital de São João, Porto, Portugal
c Serviço de Doenças Infecciosas, Hospital de São João, Porto, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Fungal endocarditis &#40;FE&#41; is a rare condition with high mortality and poor prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleItalic">Candida albicans</span> is the most frequent causative agent&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> Among the risk factors for fungemia and FE are prosthetic heart valves&#44; prolonged use of central venous catheters&#44; parenteral nutrition&#44; exposure to broad-spectrum antibiotics and immunosuppression&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleItalic">Candida</span> endocarditis is more commonly found in patients with prosthetic heart valves and occurs more often in patients with a history of prior endocarditis<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a> and early in the postoperative period&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a> Treatment includes prompt institution of antifungal therapy&#44; valve replacement and long-term eradication therapy&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 38-year-old woman with a history of surgically corrected tetralogy of Fallot at the age of 11&#44; and recent dental procedures&#44; presented with fever&#44; anorexia&#44; weight loss and fatigue for one month and epigastric pain of recent onset&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">On physical examination the patient was pale and presented with bilateral lower limb edema&#44; jugular distension and a grade II&#47;IV diastolic murmur on the left sternal border&#46; Laboratory tests showed elevated C-reactive protein &#40;CRP&#41;&#44; anemia and thrombocytopenia&#46; Blood cultures were negative&#46; Abdominal computed tomography &#40;CT&#41; revealed hepatomegaly and splenomegaly with splenic infarct&#44; thought to result from septic embolism&#46; The transthoracic echocardiogram &#40;TTE&#41; revealed an extremely mobile 15-mm vegetation on the right coronary cusp of the aortic valve and severe aortic regurgitation&#44; accompanying previously known severe dilation of the right heart chambers and pulmonary regurgitation&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A diagnosis of infective endocarditis was made and empirical antibiotic therapy was initiated with amoxicillin-clavulanate and gentamicin&#44; prior to transfer to our hospital&#46; After 17 days of antibiotic therapy&#44; signs of congestive heart failure and infection persisted and the patient was referred to our cardiothoracic surgery center&#46; Replacement of the aortic and pulmonary valves with 23- and 25-mm Carpentier-Edwards Perimount Magna<span class="elsevierStyleSup">&#174;</span> bioprostheses&#44; respectively&#44; reconstruction of the right ventricular outflow tract&#44; and tricuspid valve ring annuloplasty were successfully performed&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In the postoperative period&#44; the patient presented with nonoliguric acute renal failure and continuous renal replacement therapy &#40;catheter-based hemodialysis&#41; was instituted&#46; The patient was discharged 53 days after admission on a hemodialysis program and with no evidence of prosthetic infection on TTE&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Three days after discharge she was readmitted with fever and dyspnea&#44; along with elevated CRP and anemia&#46; Blood cultures were positive for <span class="elsevierStyleItalic">C&#46; albicans</span>&#46; Antifungal therapy with liposomal amphotericin B was initiated but subsequent blood cultures remained positive&#46; A transesophageal echocardiogram &#40;TEE&#41; demonstrated large vegetations on the aortic valve and a periprosthetic leak resulting in mild aortic regurgitation&#44; establishing the diagnosis of FE &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">At redo surgery the pulmonary prosthesis was also found to contain large vegetations &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41; and both prosthetic valves were replaced by cryopreserved homografts&#46; Microbiological analysis of the removed tissue revealed <span class="elsevierStyleItalic">C&#46; albicans</span>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">In the postoperative period blood cultures became negative and renal function recovered&#46; Due to pancytopenia&#44; liposomal amphotericin B therapy was switched to intravenous fluconazole&#46; Five days after surgery&#44; the patient suffered acute ischemia of the right lower limb and right iliofemoral embolectomy was performed by vascular surgery&#46; Direct examination of the thrombus revealed <span class="elsevierStyleItalic">C&#46; albicans</span> hyphae&#46; TTE and cardiac magnetic resonance imaging showed no signs of cardiac infection&#46; Thoracoabdominal CT revealed a pseudoaneurysm of the right iliac artery &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#44; the probable source of the emboli&#44; and the patient was reoperated&#44; with resection of the aneurysm and replacement by a segment of reversed saphenous vein&#46; Clinical pathological analysis confirmed its infectious etiology and the diagnosis of mycotic aneurysm&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The patient&#39;s condition improved and she was discharged eight weeks after the second cardiac surgery&#44; on suppressive antifungal therapy with oral fluconazole and surveillance by imaging studies and blood cultures&#46; Expected time of treatment will be at least a year&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Prosthetic valve endocarditis &#40;PVE&#41; is the most severe form of infective endocarditis&#44; accounting for 10-30&#37; of all cases&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> Health care-associated infections have been found to account for 37&#37; of PVE&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a> The risk is higher in the first year after valve replacement surgery for both mechanical and bioprosthetic valves&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Fungal etiology accounts for 2-4&#37; of all cases of endocarditis&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> Its incidence has increased in recent decades due to a growing number of patients at risk&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> It is associated with worse prognosis<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> and 50&#37; mortality rate despite treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">PVE is a diagnostic challenge&#58; the modified Duke criteria<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a> lack sensitivity in this context&#44; blood cultures are more often negative and echocardiography has less diagnostic accuracy&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> Therefore&#44; a high index of suspicion is needed for its diagnosis&#44; in order to enable early initiation of therapeutic measures that can improve the prognosis&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In the case reported&#44; no vegetations were identified in the pulmonary prosthesis by echocardiography&#46; This is presumably due to the poor visualization of the pulmonary prosthesis by TEE and to its lower sensitivity in cases of PVE&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">TEE is more sensitive and useful in cases of PVE&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a> FE usually leads to larger vegetations than those found in bacterial endocarditis&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a> As a result&#44; arterial embolization&#44; as presented by our patient&#44; is more common&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a> the usual sites being the cerebral circulation&#44; extremities and gastrointestinal tract&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">No randomized studies have assessed the optimal therapy for fungal PVE&#46; The therapeutic approach is based on antifungal agents and valve replacement surgery&#44; although successful treatments of FE have been reported with medical therapy alone&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> Moreover&#44; no uniform recommendations are available concerning the most appropriate antimicrobial regimen&#44; the ideal timing for surgery or the total duration of treatment&#46; According to the ESC guidelines&#44; surgery may be undertaken on an elective or urgent basis depending on the patient&#39;s condition&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> although others recommend earlier surgery&#44; as it appears to improve outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a> In the case presented&#44; an initial approach with antifungal therapy was adopted&#44; due to the high risk associated with a third cardiac surgery &#40;EuroSCORE II of 38&#46;5&#41;&#44; but the persistent fungemia made surgery advisable&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In our patient&#44; amphotericin B was used in a lipid formulation to avoid further deterioration of renal function&#44; but the development of pancytopenia forced conversion to fluconazole&#46; Since the potential for recurrent infection is extremely high in fungal PVE&#44; suppressive therapy with fluconazole is recommended for prolonged periods or even indefinitely&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Given the high recurrence rate of FE&#44; the use of homografts is justified by their higher resistance to recurrent infection&#46; This advantage may be explained by the suggestion that homografts have the ability to reproduce collagen&#44; improving postoperative local healing&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> Homografts allow complete debridement of all infected tissue and better tissue penetration of antimicrobial agents&#44; facilitating eradication of the infection&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The source of our patient&#39;s candidemia is unclear&#44; but the long hospitalization&#44; the presence of a recent implanted prosthetic valve&#44; and an indwelling central venous catheter for the hemodialysis program represent risk factors that may explain it&#46; The patient&#39;s congenital heart disease is also a predisposing factor for infective endocarditis&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In this case numerous predictors of poor outcome were present&#44; besides the fungal etiology of a prosthetic valve infection&#46; These included the clinical manifestations of congestive heart failure&#44; the long period of hospitalization with central venous catheters&#44; renal failure requiring hemodialysis&#44; the large size of the fungal vegetations&#44; carrying higher embolic risk&#44; and finally the mycotic pseudoaneurysm of the right iliac artery&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0100" class="elsevierStylePara elsevierViewall">FE caused by <span class="elsevierStyleItalic">C&#46; albicans</span> is a rare condition with poor prognosis&#46; The presence of a prosthetic valve and a central venous catheter are major risk factors for FE&#46; The diagnosis is challenging as only about half of blood cultures are positive and the sensitivity of echocardiography in prosthetic valve endocarditis is limited&#46; Despite the lack of evidence from randomized clinical trials&#44; treatment combining antifungal therapy and valve replacement is thought to offer improved clinical outcomes&#46; The timing of surgery is not consensual but early surgery appears to improve survival&#44; depending on the patient&#39;s clinical condition&#46; Moreover&#44; given the high recurrence rate of fungal PVE&#44; homografts appear to be the most appropriate choice&#44; providing the highest resistance to recurrent infection&#44; by allowing complete debridement of infected tissue with low risk of valve dehiscence and better antibiotic penetration&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            0 => "Fungal endocarditis"
            1 => "Prosthetic valve endocarditis"
            2 => "<span class="elsevierStyleItalic">Candida albicans</span>"
            3 => "Homografts"
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            2 => "<span class="elsevierStyleItalic">Candida albicans</span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Fungal prosthetic valve endocarditis is an extremely severe form of infective endocarditis&#44; with poor prognosis and high mortality despite treatment&#46; <span class="elsevierStyleItalic">Candida albicans</span> is the most common etiological agent for this rare but increasingly frequent condition&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We present a case of fungal prosthetic valve endocarditis due to <span class="elsevierStyleItalic">C&#46; albicans</span> following aortic and pulmonary valve replacement in a 38-year-old woman with a history of surgically corrected tetralogy of Fallot&#44; prior infective endocarditis and acute renal failure with need for catheter-based hemodialysis&#46; Antifungal therapy with liposomal amphotericin B was initiated prior to cardiac surgery&#44; in which the bioprostheses were replaced by homografts&#44; providing greater resistance to recurrent infection&#46; During hospitalization&#44; a mycotic aneurysm was diagnosed following an episode of acute arterial ischemia&#44; requiring two vascular surgical interventions&#46; Despite the complications&#44; the patient&#39;s outcome was good and she was discharged on suppressive antifungal therapy with oral fluconazole for at least a year&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The reported case illustrates multiple risk factors for fungal endocarditis&#44; as well as complications and predictors of poor prognosis&#44; demonstrating its complexity&#46;</p></span>"
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        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A endocardite f&#250;ngica de pr&#243;tese valvular &#233; uma forma extremamente severa de endocardite infeciosa&#44; com mau progn&#243;stico e elevada mortalidade apesar do tratamento m&#233;dico&#46; <span class="elsevierStyleItalic">Candida albicans</span> &#233; o agente etiol&#243;gico mais frequentemente implicado nesta rara&#44; embora crescente&#44; patologia&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Relata-se um caso de endocardite f&#250;ngica de pr&#243;tese valvular ap&#243;s substitui&#231;&#227;o das v&#225;lvulas a&#243;rtica e pulmonar numa mulher de 38 anos com antecedentes de tetralogia de Fallot cirurgicamente corrigida&#44; endocardite infeciosa pr&#233;via e insufici&#234;ncia renal aguda com necessidade de hemodi&#225;lise por cat&#233;ter&#46; A terap&#234;utica antif&#250;ngica com anfotericina B liposs&#243;mica foi iniciada previamente &#224; cirurgia card&#237;aca&#44; onde as biopr&#243;teses foram substitu&#237;das por homoenxertos&#44; conferindo maior resist&#234;ncia &#224; infe&#231;&#227;o recorrente&#46; Durante o internamento&#44; foi diagnosticado um aneurisma mic&#243;tico&#44; na sequ&#234;ncia de um epis&#243;dio de isquemia arterial aguda&#44; obrigando a duas interven&#231;&#245;es pela Cirurgia Vascular&#46; Apesar das complica&#231;&#245;es&#44; a doente teve um bom <span class="elsevierStyleItalic">outcome</span> cl&#237;nico e recebeu alta com terap&#234;utica de erradica&#231;&#227;o com fluconazol durante&#44; pelo menos&#44; um ano&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">O caso relatado enumera m&#250;ltiplos fatores de risco para endocardite f&#250;ngica&#44; assim como complica&#231;&#245;es e preditores de mau progn&#243;stico&#44; ilustrando a sua complexidade&#46;</p></span>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram&#44; long-axis aortic valve plane&#44; demonstrating the presence of a vegetation in the aortic prosthesis &#40;arrow&#41;&#46; Ao&#58; ascending aorta&#59; LA&#58; left atrium&#59; LV&#58; left ventricle&#46;</p>"
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Article information
ISSN: 21742049
Original language: English
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Idiomas
Revista Portuguesa de Cardiologia (English edition)
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