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Baman JR, Medhekar AN, Jain SK, Knight BP, Harrison LH, Smith B, Saba S. Management of systemic fungal infections in the presence of a cardiac implantable electronic device: A systematic review. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 44:159-166. [PMID: 33052591 DOI: 10.1111/pace.14090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/26/2020] [Accepted: 10/11/2020] [Indexed: 12/16/2022]
Abstract
Evidence to inform the management of systemic fungal infections in the setting of a cardiac implantable electronic devices (CIED), such as a permanent pacemaker or implantable cardioverter-defibrillator, is scant and limited to case reports and series. The available literature suggests high morbidity and mortality. To better characterize the shared experience of these cases and their outcomes, we performed a systematic review. We investigated all published reports of systemic fungal infections-fungemia and fungal vegetative disease-in the context of CIED, drawing from PubMed, EMBASE, and the Cochrane database of systematic reviews, inclusive of patients who received treatment between January 2000 and May 2020. Exclusion criteria included presence of ventricular assist device and concurrent bacteremia, bacterial endocarditis, bacterial vegetative infection, or viremia. Among 6261 screened articles, 48 cases from 41 individual studies were identified. Candida and Aspergillus species were the most commonly isolated fungi. There was significant heterogeneity in antifungal medication selection and duration. CIED extraction-either transvenous or surgical-was associated with increased survival to hospital discharge (92%) and clinical recovery at latest follow-up (81%), compared to cases where CIED extraction was deferred (56% and 40%, respectively). Importantly, there were no prospective data, and the data were limited to individual case reports and one small case series. In summary, CIED extraction is associated with improved fungal clearance and patient survival. Reported antifungal regimens are heterogeneous and nonuniform. Prospective studies are needed to verify these results and define optimal antifungal regimens.
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Affiliation(s)
- Jayson R Baman
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ankit N Medhekar
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sandeep K Jain
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Bradley P Knight
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lee H Harrison
- Infectious Diseases Epidemiology Research Unit, School of Medicine and Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Brandon Smith
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Samir Saba
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Raut N, Potdar A, Sharma S. Tricuspid valve endocarditis in non-drug abusers: A case series from India. Indian Heart J 2018; 70:476-481. [PMID: 30170639 PMCID: PMC6116710 DOI: 10.1016/j.ihj.2017.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/30/2017] [Accepted: 09/15/2017] [Indexed: 11/17/2022] Open
Abstract
Objective The etiology of tricuspid valve endocarditis (TVE) seems to be different in our country as intravenous (IV) drug abuse is not known to be a major health hazard. The objective of this communication is to study the risk factors, clinical profile, follow-up data of TVE patients and focus on the difficulties in diagnosis and variations encountered. Methods A retrospective analysis of data of 10 patients of TVE managed in a tertiary care center during January 1992 to June 2015 was done. Results TVE was encountered in a diverse subset of patients with cardiac implantable electronic device (CIED) (group I; 3 patients), immunocompromised state with indwelling central venous catheter (CVC) (group II; 2 patients), congenital heart disease (CHD) (group III; 3 patients) and in apparently healthy individuals (group IV; 2 patients). Blood cultures were negative in half the patients. In group I early surgical extraction of leads, device and vegetation provided excellent results. Prognosis was poor with 100% mortality in immunocompromised patients. Patients in group III did well on medical management. The overall mortality was high (30% in hospital and additional 20% within one year). Conclusions TVE is rare and can occur in different clinical scenarios. Indiscriminate use of antibiotics modifies the clinical picture causing delay in diagnosis and referral to speciality care. Echocardiography remains the main modality and should be used serially to facilitate early diagnosis. The prognosis is guarded. Early surgery is recommended in pacemaker lead, fungal endocarditis, persistent sepsis or hemodynamic instability for favorable prognosis.
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Affiliation(s)
- Nikhil Raut
- Department of Cardiology, Bombay Hospital and Bombay Hospital Institute of Medical Sciences, Mumbai, India.
| | - Anil Potdar
- Department of Cardiology, Bombay Hospital and Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Satyavan Sharma
- Department of Cardiology, Bombay Hospital and Bombay Hospital Institute of Medical Sciences, Mumbai, India
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Abstract
Sixty years after its initial description, right-sided infective endocarditis (RSIE) still poses a challenge to all medical practitioners. Epidemiological data reveal a rising incidence attributable to the global surge in the number of intravenous drug users and the increased use of central vascular catheters and implantable cardiac devices. RSIE differs from left-sided infective endocarditis in more than just the location of the involved cardiac valve. They have different clinical presentations, diagnostic findings, and prognoses; hence, they require different management strategies. Cardiac murmurs and systemic emboli are usually absent in RSIE, whereas pulmonary embolism and its related complications dominate the clinical picture. Diagnostic delay of RSIE is secondary to the similarity in its initial presentation to other entities. Complications may ensue as a result of this delay. Diagnosis can be initially confirmed by using transthoracic echocardiography, except in patients with implanted cardioverter defibrillator, where a transesophageal echocardiogram is necessary. Various factors may increase mortality and morbidity in RSIE such as tricuspid valve vegetation size, fungal etiology, and low CD4 cell count in HIV patients. Oxacillin and vancomycin had been the traditionally used agents for the treatment of methicillin-susceptible and methicillin-resistant Staphylococcus aureus, respectively. More recently, daptomycin has shown promising results, which has led to its Food and Drug Administration (FDA) approval for the treatment of S. aureus bacteremia and associated RSIE. The aim of this article is to provide a comprehensive update on RSIE including epidemiology, pathogenesis, microbiology, diagnosis, management, and prognosis.
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Rofaiel R, Turkistani Y, McCarty D, Hosseini-Moghaddam SM. Fungal mobile mass on echocardiogram: native mitral valve Aspergillus fumigatus endocarditis. BMJ Case Rep 2016; 2016:bcr-2016-217281. [PMID: 27932432 DOI: 10.1136/bcr-2016-217281] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The most common type of infective endocarditis is bacterial endocarditis. However, fungal infections have been seen more frequently, mostly in the immunocompromised population. We report a case of invasive Aspergillus fumigatus native mitral valve endocarditis. The patient received appropriate empiric antifungal treatment with a combination of liposomal amphotericin B and flucytosine, associated with surgical debridement, valve replacement and chordae tendineae repair. Despite receiving the standard treatment of Aspergillus endocarditis, and susceptibility of the microorganism to the antifungal regimen, the patient, unexpectedly, developed early-onset septic emboli. It is surprising to see that the patient had developed such complications early, despite attempts to eliminate the source of infection with surgical intervention.
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Affiliation(s)
- Rymon Rofaiel
- Department of Medicine, Western University, London, Ontario, Canada
| | - Yosra Turkistani
- Department of Cardiology, Western University, London, Ontario, Canada
| | - David McCarty
- Department of Cardiology, Western University, London, Ontario, Canada
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Bandyopadhyay S, Tiwary PK, Mondal S, Puthran S. Pacemaker lead Candida endocarditis: Is medical treatment possible? Indian Heart J 2015; 67 Suppl 3:S100-2. [PMID: 26995411 PMCID: PMC4799021 DOI: 10.1016/j.ihj.2015.11.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 10/22/2015] [Accepted: 11/16/2015] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - P K Tiwary
- Apollo Gleneagles Hospital, Kolkata, India
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Aspergillus fumigatus en cardiodesfibrilador implantado cinco años antes. REVISTA COLOMBIANA DE CARDIOLOGÍA 2014. [DOI: 10.1016/j.rccar.2014.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Pincus JL, Jahng M, Massie L, Lee SA. Early Aspergillus pacemaker pocket infection: Case and review. Med Mycol Case Rep 2012; 1:32-4. [PMID: 24371732 DOI: 10.1016/j.mmcr.2012.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 05/02/2012] [Accepted: 05/11/2012] [Indexed: 10/28/2022] Open
Abstract
We report the first case to our knowledge of an early pacemaker pocket infection due to Aspergillus fumigatus. Several cases of late pacemaker pocket infection by Aspergillus have been reported, but it remains exceedingly rare. Recognition of Aspergillus infection as a potential early or late complication of placement of pacemakers or implantable cardioverter defibrillator devices may help clinicians diagnose and treat future cases of this potentially devastating infection.
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Affiliation(s)
- Jennifer L Pincus
- New Mexico Veterans Healthcare System, 1501 San Pedro SE, Mail Code 111-J, Albuquerque, NM 87108, USA ; Division of Pathology, The University of New Mexico Health Sciences Center, 1 University of New Mexico, Albuquerque, NM 87131, USA
| | - Maximillian Jahng
- New Mexico Veterans Healthcare System, 1501 San Pedro SE, Mail Code 111-J, Albuquerque, NM 87108, USA
| | - Larry Massie
- New Mexico Veterans Healthcare System, 1501 San Pedro SE, Mail Code 111-J, Albuquerque, NM 87108, USA ; Division of Pathology, The University of New Mexico Health Sciences Center, 1 University of New Mexico, Albuquerque, NM 87131, USA
| | - Samuel A Lee
- New Mexico Veterans Healthcare System, 1501 San Pedro SE, Mail Code 111-J, Albuquerque, NM 87108, USA ; Division of Infectious Diseases, The University of New Mexico Health Sciences Center, 1 University of New Mexico, Albuquerque, NM 87131, USA
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Kalokhe AS, Rouphael N, El Chami MF, Workowski KA, Ganesh G, Jacob JT. Aspergillus endocarditis: a review of the literature. Int J Infect Dis 2010; 14:e1040-7. [PMID: 21036091 DOI: 10.1016/j.ijid.2010.08.005] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 08/19/2010] [Accepted: 08/19/2010] [Indexed: 11/17/2022] Open
Abstract
We present a case of cardiac device-related Aspergillus endocarditis in a patient with a pacemaker and an allogeneic bone marrow transplant to segue into a review of the Aspergillus endocarditis literature. Aspergillus endocarditis should be suspected in patients with underlying immunosuppression, negative cultures, and a vegetation on echocardiography. Diagnosis ultimately requires confirmation by tissue histology and culture. The optimal treatment approach often requires aggressive surgical debridement in conjunction with prolonged antifungal therapy.
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Affiliation(s)
- Ameeta S Kalokhe
- Infectious Diseases, Emory University, 206 Woodruff Research Extension Bldg, 49 Jesse Hill Jr. Drive, Atlanta, GA 30303, USA.
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Chakrabarti A, Chatterjee SS, Das A, Shivaprakash MR. Invasive aspergillosis in developing countries. Med Mycol 2010; 49 Suppl 1:S35-47. [PMID: 20718613 DOI: 10.3109/13693786.2010.505206] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
To review invasive aspergillosis (IA) in developing countries, we included those countries, which are mentioned in the document of the International Monetary Fund (IMF), called the Emerging and Developing Economies List, 2009. A PubMed/Medline literature search was performed for studies concerning IA reported during 1970 through March 2010 from these countries. IA is an important cause of morbidity and mortality of hospitalized patients of developing countries, though the exact frequency of the disease is not known due to inadequate reporting and facilities to diagnose. Only a handful of centers from India, China, Thailand, Pakistan, Bangladesh, Sri Lanka, Malaysia, Iran, Iraq, Saudi Arabia, Egypt, Sudan, South Africa, Turkey, Hungary, Brazil, Chile, Colombia, and Argentina had reported case series of IA. As sub-optimum hospital care practice, hospital renovation work in the vicinity of immunocompromised patients, overuse or misuse of steroids and broad-spectrum antibiotics, use of contaminated infusion sets/fluid, and increase in intravenous drug abusers have been reported from those countries, it is expected to find a high rate of IA among patients with high risk, though hard data is missing in most situations. Besides classical risk factors for IA, liver failure, chronic obstructive pulmonary disease, diabetes, and tuberculosis are the newly recognized underlying diseases associated with IA. In Asia, Africa and Middle East sino-orbital or cerebral aspergillosis, and Aspergillus endophthalmitis are emerging diseases and Aspergillus flavus is the predominant species isolated from these infections. The high frequency of A. flavus isolation from these patients may be due to higher prevalence of the fungus in the environment. Cerebral aspergillosis cases are largely due to an extension of the lesion from invasive Aspergillus sinusitis. The majority of the centers rely on conventional techniques including direct microscopy, histopathology, and culture to diagnose IA. Galactomannan, β-D glucan test, and DNA detection in IA are available only in a few centers. Mortality of the patients with IA is very high due to delays in diagnosis and therapy. Antifungal use is largely restricted to amphotericin B deoxycholate and itraconazole, though other anti-Aspergillus antifungal agents are available in those countries. Clinicians are aware of good outcome after use of voriconazole/liposomal amphotericin B/caspofungin, but they are forced to use amphotericin B deoxycholate or itraconazole in public-sector hospitals due to economic reasons.
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Affiliation(s)
- Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India.
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