Case Study
Introduction Invasive aspergillosis is a life-threatening , opportunistic infection that occurs most often in immunocompromised patients . Myocardial abscess is a rare and potentially fatal condition . Metastatic myocardial abscess , in the setting of infective endocarditis , has been infrequently reported . Herein , we report a case of disseminated aspergillus infection with vertebral body osteomyelitis , renal aspergillosis , myocardial abscess , and endocarditis in a liver-transplant patient . A high index of clinical suspicion is required to make a prompt diagnosis . Final diagnosis may need a combination of serological tests and imaging , particularly in instances where biopsy is non-yielding or cannot be performed .
by Rashmi Balasubramanya 1 ; Achala Donuru MBBS , FRCR 2 ; Vinay Kandula , MBBS , FRCR 3 ; Joanna Chan MD 2 ; Maruti Kumaran , MD 4 ; Maansi Parekh , MBBS , DNB 1
1 . Department of Radiology , Thomas Jefferson University Hospitals , 132 S 10th St , 1079 Main Building , Philadelphia , PA 2 . Department of Pathology , Thomas Jefferson University Hospitals , 132 S 10th St , Suite 285 Main Building , Philadelphia , PA
3 . Department of Medical Imaging , 1600 Rockland Rd , Wilmington , DE 4 . Department of Radiology , Temple University Hospitals , 3401 N Broad St , Philadelphia , PA
Disseminated Aspergillus of the Heart : A Case Report of Intracavitary , Myocardial , and Valvular Fungal Involvement
Case Description A 64-year-old female underwent liver transplantation for fulminant Hepatitis A liver failure six months earlier . She presented to the hospital with pain radiating down her right lower extremity . She complained of chronic lumbosacral back pain that had persisted ever since her transplant , however progressively worsened . She denied any numbness , tingling , or loss of sensation . MRI of the spine was ordered , which revealed osteomyelitis and discitis of L2 / 3 with an epidural phlegmon ( Figure 1 ). Incidentally , she was found to have a new hypodense right kidney lesion ( Figure 2 ). Biopsy of the epidural phlegmon and right kidney lesion revealed aspergillus ( Figure 3 ). Serum aspergillus
galactomannan antigen was positive at that time . She was started on Amphotericin B and eventually transitioned to Isavuconazole as her QT prolongation on EKG did not allow for Voriconazole . Chest CT performed for new onset hypoxia revealed a filling defect in the left atrium ( Figure 4 ) and an additional low density myocardial mass arising from the free wall of the left ventricle felt to represent a myocardi-
Figure 3 : Contrast-enhanced image from a Chest CT demonstrates a lobulated filling defect in the left atrium , along the ligament of Marshall ( warfarin ridge ).
Figure 2 : Rim-enhancing lesion in the right upper renal pole concerning for an abscess ( arrow ).
Figure 1 : MRI lumbar spine post contrast sagittal image demonstrates avid enhancement involving the L3 and L4 vertebral bodies with associated endplate deformities
Figure 3 : Biopsy of the right renal lesion . Fungal elements with 45-degree branching consistent with aspergillus species . H & E 400x
Figure 5 : Contrast-enhanced image from a Chest CT demonstrates a hypodense lesion arising from the left ventricular lateral wall myocardium . Low attenuation in the center suggests necrosis .
86 • The Journal of the Arkansas Medical Society www . ArkMed . org