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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 21  |  Issue : 1  |  Page : 38-39

Fungal prosthetic valve endocarditis by amphotericin-resistant Candida parapsilosis: A case report from South Kerala


Department of Microbiology, Travancore Medical College, Kollam, Kerala, India

Date of Web Publication12-Aug-2019

Correspondence Address:
Dr. K M Rafeeda
Department of Microbiology, Travancore Medical College, Kollam, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacm.jacm_1_19

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  Abstract 


Fungal prosthetic valve endocarditis is a rare but serious complication of valve replacement surgery. We describe a case report of prosthetic valve endocarditis caused by Candida parapsilosis resistant to Amphotericin B, and the patient was completely recovered due to prompt redo surgery and with Caspofungin and Fluconazole therapy.

Keywords: Amphotericin B, Candida parapsilosis, Caspofungin, prosthetic valve endocarditis


How to cite this article:
Rafeeda K M, Geethanjali M, Umapathy B L, Mathew M. Fungal prosthetic valve endocarditis by amphotericin-resistant Candida parapsilosis: A case report from South Kerala. J Acad Clin Microbiol 2019;21:38-9

How to cite this URL:
Rafeeda K M, Geethanjali M, Umapathy B L, Mathew M. Fungal prosthetic valve endocarditis by amphotericin-resistant Candida parapsilosis: A case report from South Kerala. J Acad Clin Microbiol [serial online] 2019 [cited 2019 Oct 23];21:38-9. Available from: http://www.jacmjournal.org/text.asp?2019/21/1/38/264243




  Introduction Top


Prosthetic valve endocarditis (PVE) is a potentially life-threatening infection that involves a valve prosthesis or annuloplasty ring. Fungal PVE is associated with high rates of treatment failure, relapse and mortality. The Candida and Aspergillus species are the two most common etiologic fungi found responsible for fungal endocarditis. Among Candida, Candida parapsilosis and Candida tropicalis, although rare, can be devastating.[1] C. parapsilosis is an emerging pathogen, and early detection and prompt initiation of appropriate treatment could reduce the morbidity and mortality.


  Case Report Top


A middle aged lady who had rheumatic heart disease had undergone mitral valve replacement (Perimount Magna mitral ease 25 mm) for severe calcific mitral stenosis and mitral regurgitation on May 2015. She was leading a normal life with cardiac medications for three years. The current episode started as fever and cough of three-week duration not responding to two courses of antibiotics. On admission, the patient was febrile and haemodynamically stable. Echocardiography showed vegetation within the anterior leaflet of prosthetic valve. Blood culture was done by BACT/ALERT (bioMerieux), and smear after the signal showed oval Gram-positive budding yeast cells following which the patient was started with Amphotericin B. Sabouraud dextrose agar and Chrome Agar showed growth of creamy white opaque colonies after 24 h of incubation, and germ tube test was negative. Species identification was done with VITEK 2 (bioMerieux) and identified as C. parapsilosis. A total of 12 blood culture samples yielded C. parapsilosis. The isolate was sensitive to Fluconazole (MIC [minimum inhibitory concentration]– 2 μg), Caspofungin (MIC – 1 μg) and Flucytosine (MIC – 1 μg) and was resistant to Amphotericin B (MIC ≥16 μg). Redo surgery was done, and the vegetations and prosthetic valve were also sent for fungal culture, which also yielded the same fungi with the same sensitivity pattern as blood culture. Antifungal therapy was changed to Caspofungin and Fluconazole, and the patient responded well. After redo surgery, blood samples were cultured, and no fungus was isolated. The patient was continued with the antifungal for three months and discharged with an advice of continuing Caspofungin for one week and Fluconazole for one month.


  Discussion Top


Fungal PVE is an infrequent but serious complication of valve replacement surgery. Candida-infective endocarditis has a bad prognosis in those patients not operated early, and one important predisposing factor is prosthetic valve.[2]

C. parapsilosis, although initially considered non-pathogenic, was identified as the causative agent of a fatal case of endocarditis in an intravenous drug user in 1940. C. parapsilosis infections are especially associated with hyperalimentation solutions, prosthetic devices and indwelling catheters, as well as the nosocomial spread of disease through the hands of healthcare workers. Factors involved in disease pathogenesis are the secretion of hydrolytic enzymes, adhesion to prosthetics and biofilm formation.[3]

Fungal endocarditis accounts for 1.3%–6% of all infective endocarditis cases, and its incidence has increased over the past two decades as a result of improvements in diagnosis and treatment. C. parapsilosis is associated with 17% of the identified cases of fungal endocarditis, making it the second most common species after Candida albicans.[3]

Currently, the most common predisposing factors for C. parapsilosis endocarditis include prosthetic valves (57.4%), intravenous drug use (20%), intravenous parenteral nutrition (6.9%), abdominal surgery (6.9%), immunosuppression (6.4%), treatment with broad-spectrum antibiotics (5.6%) and previous valvular disease (4.8%).[4]

Amphotericin B was resistant with an MIC value of ≥16 μg in the current case. It has a relatively broad spectrum of action and is useful in treating cases of Candida infections. Resistance (MIC >2 μ g/L) tends to be species dependent and emerges uncommonly and slowly in isolates from patients treated with Amphotericin B.[5]

Echinocandins include Caspofungin, Micafungin and Anidulafungin. Caspofungin has potent antifungal activities and has been shown to be as effective as, and less toxic than, Amphotericin B in the treatment of invasive candidiasis caused by C. albicans, C. parapsilosis, C. tropicalis, Candida glabrata, Candida krusei, Candida guilliermondii, Candida lipolytica and Candida rugosa. However, Caspofungin MICs for C. parapsilosis are higher than those for other Candida species, with average MIC50 and MIC90 values ranging between 0.85–2 μg/ml and 2–2.33 μg/ml, respectively, particularly in clinical cases involving C. parapsilosis isolates resistant to Amphotericin B, Fluconazole or both.[5]

Combination therapy with echinocandins and Amphotericin B or azoles is being examined for different invasive mycoses.[6]

Prompt identification and antifungal susceptibility of C. parapsilosis endocarditis is very important as the usual line of treatment is an administration of Amphotericin B. This case report emphasises that whenever there is a non-albicans Candida spp. isolated from invasive infections, the sensitivity also has to be reported which is very essential to save the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Palraj R, Bettina M, Larry MB, Walter RW. In: Bennet JE, Dolin R, Blaser Mandell MJ, editors. Douglass and Bennets Principles and Practices of Infectious Diseases. 8th ed. Philadelphia: Elsevier Saunders; 2015. p. 1029-40.  Back to cited text no. 1
    
2.
Branco L, Pitta ML, Bernardes L, Galrinho A, Agapito AF, Ramos JM, et al. Areview of infectious endocarditis due to candida. Rev Port Cardiol 1997;16:967-74, 955.  Back to cited text no. 2
    
3.
Trofa D, Gácser A, Nosanchuk JD. Candida parapsilosis, an emerging fungal pathogen. Clin Microbiol Rev 2008;21:606-25.  Back to cited text no. 3
    
4.
Garzoni C, Nobre VA, Garbino J. Candida parapsilosis endocarditis: A comparative review of the literature. Eur J Clin Microbiol Infect Dis 2007;26:915-26.  Back to cited text no. 4
    
5.
Ellis D. Amphotericin B: Spectrum and resistance. J Antimicrob Chemother 2002;49 Suppl 1:7-10.  Back to cited text no. 5
    
6.
Mukherjee PK, Sheehan DJ, Hitchcock CA, Ghannoum MA. Combination treatment of invasive fungal infections. Clin Microbiol Rev 2005;18:163-94.  Back to cited text no. 6
    




 

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