Conservative clinical treatment with systemic antifungal therapy can be an effective approach for fungal endocarditis in patients with high surgical risk or contraindications to surgery.
Fungal endocarditis is a rare and severe form of infective endocarditis, mainly caused by fungi of the genera Candida and Aspergillus , with high mortality, especially when diagnosis is delayed. We report two distinct cases of fungal endocarditis involving the native aortic valve, with different clinical presentations and therapeutic approaches. The first case involved a 23-year-old female patient with ulcerative colitis, hospitalized in December 2024 due to an acute colitis flare, which progressed to intestinal perforation after colonoscopy, requiring surgical intervention and prolonged parenteral nutrition. She developed a surgical site infection requiring reintervention, with cultures positive for multidrug-resistant Pseudomonas aeruginosa , leading to prolonged broad-spectrum antibiotic therapy. She subsequently developed positive blood cultures for Candida parapsilosis and an echocardiogram compatible with fungal endocarditis of the aortic valve. After treatment with micafungin, there was a slight reduction in vegetation on follow-up echocardiography. After clinical improvement, she was discharged on oral antifungal therapy. The second case involved a 64-year-old male patient with a history of alcoholism and smoking, admitted with weight loss, dyspnea, and ascites, diagnosed with pneumonia, heart failure with an ejection fraction of 32%, liver cirrhosis, and Chagas disease. On the 17th day of hospitalization, he developed candidemia due to Candida tropicalis and micafungin was initiated. Echocardiography demonstrated vegetation suggestive of fungal endocarditis of the aortic valve. Due to high surgical risk, conservative clinical treatment was chosen. After 21 days of micafungin with negative cultures, oral fluconazole was initiated, and the patient was discharged. The cases illustrate the importance of a high index of suspicion for early diagnosis of fungal endocarditis, especially in patients with risk factors such as immunosuppression, parenteral nutrition, and prolonged antibiotic use. Treatment requires systemic antifungal therapy and, whenever possible, surgical intervention. In patients with contraindications to surgery, a clinical approach may be effective. Repeated blood cultures and echocardiography, preferably transesophageal, are essential for diagnosis and therapeutic monitoring.
Oliveira et al. (Sun,) studied this question.