Tricuspid Valve Vegetation in Neonatal Candida Endocarditis

To the Editors: Neonatal fungal endocarditis is rare, yet carries a dismal prognosis. We report a term neonate who developed Candida albicans sepsis with a large tricuspid valve vegetation and disseminated candidiasis, highlighting the importance of early echocardiographic evaluation in septic neonates. A 36 + 5 weeks' gestation female neonate, delivered via cesarean for prolonged labor, presented with respiratory distress and poor feeding by day 7 of life. Laboratory tests showed thrombocytopenia (platelets 68,000/µL) and elevated c-reactive protein (27 mg/L). Initial blood cultures grew Serratia marcescens; repeat cultures isolated C. albicans. Despite empirical antibiotics and inotropes, the infant deteriorated with signs of meningitis and persistent sepsis. Cerebrospinal fluid culture also confirmed C. albicans. Transthoracic echocardiography on day 10 revealed a large (34 × 12 mm), mobile echogenic mass attached to the anterior tricuspid leaflet, consistent with fungal vegetation (see Figure, Supplemental Digital Content 1, https://links.lww.com/INF/G370). Brain imaging showed multiple ring-enhancing lesions, consistent with cerebral fungal microabscesses. Disseminated candidiasis was diagnosed. Liposomal Amphotericin B was initiated, later escalated to voriconazole due to persistent fungemia. Serial echocardiograms showed no embolic complications, but vegetation persisted. Despite 5 weeks of antifungal therapy and intensive support, the infant succumbed to multiorgan failure and coagulopathy on day 48. Neonatal fungal endocarditis—most often caused by C. albicans—is exceedingly rare but devastating, especially in the presence of central venous catheters, parenteral nutrition and broad-spectrum antibiotics.1–3 Tricuspid vegetations are common due to right-sided catheter colonization, and their large, friable nature predisposes to embolization.4 Brain abscesses and meningitis, as seen in our case, indicate advanced dissemination and high mortality.5 Medical therapy remains the cornerstone, yet responses are often inadequate without early intervention. Surgery is rarely feasible in neonates. The outcome in our patient underscores the importance of heightened suspicion for fungal etiology in septic neonates with thrombocytopenia and persistent central line-associated sepsis. We advocate for routine early echocardiographic screening in high-risk neonatal intensive care unit patients to enable timely diagnosis and improve outcomes in this otherwise lethal condition.