Post-Cardiac Surgery Fungal Endocarditis


Parisa Badiee




Intech Open Access




Infective endocarditis (IE) is a threatening disease associated with a high risk of morbidity and mortality. The most etiologic agents are the bacteria followed by fungi. Fungal Endocarditis (FE) is an uncommon occurrence and the most severe form of IE, however, its rate has increased in recent decades. The first report of FE after a mitral valve replacement was in 1964 (1) but there have been many cases reported in recent years indicating the importance of such infections (2-4). Fungal endocarditis accounts for 1.3% to 6% of all IE cases (5-8). Ranges between 1.7 to 3.8 per 100,000 person-years have been reported in different studies for mean annual incidence (5, 9). Increase in the number of cases of fungemia and FE has been seen during the last 2 decades (10, 11). Men are more at risk of infections than women (7, 12, 13), and younger persons (third to fourth decades of life) are in more risk factor. The incidence of FE varies based on the criteria and methods of diagnosis (5) and population under survey; in liver transplants (14) the incidence of FE after transplantation was 1.7%. The mortality rate was 72% (15) but is still high (about 50%) despite the treatments (7). In an international multicenter prospective cohort study that included 33 cases of Candida endocarditis treated between 2000 and 2005, the mortality rate was 30 % (16), and in post-surgical invasive aspergillosis (17) and Aspergillus endocarditis the rate was too high (100%) even with combined medical and surgical therapy (2). Fungi are important causes of prosthetic valve endocarditis, responsible for 1%–10% of these infections (18). Also, there are reports that fungi are responsible for 9.6% of the early cases of prosthetic valve endocarditis (60 days after the insertion of prosthesis) and for 4.3% of late cases (>60 days after the insertion of prosthesis) (19, 20). The incidence of FE in culture- documented cases has been reported to range from 12% to 20% (21) or to 37.5% (22). Many fungal species cause FE, of which the most important are Candida albicans 60%-67% and filamentous Aspergillus spp. 20–30% (ratio rate 2/1) (7, 15, 23), In addition, non-albicans species of Candida, Torulopsis glabrata, Candida tropicalis, and other filamentus fungi like Aspergillus spp., Curvularia genuculata, Hormondendrum dermatitidis, Mucoracae, Scopulariopsis spp., Trichosporon spp. and Blastoschizomyces capitatus have been reported in the literature (10, 15, 22, 24, 25). In some studies, the most common etiologic agent was different, as in Rubinstein E et al. Candida parapsilosis accounts for half of the culture-documented patients, whereas C. albicans and Candida stellatoidea account for 12%-15% only (21). Pneumocystis jiroveci caused fungal infection in 9% to 11% of all heart transplant recipients in the past, with a mortality rate of 11% to 38% (26) but with use of prophylaxis, the rate of this infection has decreased.