Figure 6 : Round , mobile mass with septations attached to the lateral wall of the left atrium ( arrow ).
Figure 7 : Round , mobile mass with septations attached to the lateral wall of the left atrium ( arrow ) without internal vascularity .
Figure 8 : Filling defect in the right atrium ( arrow ).
al abscess invading into the epicardium , and possibly the pericardium ( Figure 5 ). Transesophageal echocardiogram was performed for further characterization and revealed a mobile mass with septations in the left atrium , atypical for a thrombus ( Figure 6 , 7 ). Hence , the constellation of findings was felt to be most consistent with cardiac involvement of aspergillus . Repeat imaging showed an increase in size in these lesions and a new right atrial lesion ( Figure 8 ) despite therapy with
Isavuconazole . The cardiothoracic surgical team was consulted ; however , given prognosis and extensive nature and high risk of surgical intervention , no biopsy or surgical intervention of cardiac lesions was performed .
Discussion Invasive aspergillosis is a serious opportunistic infection that occurs in a variety of immunocompromised patients such as those receiving chemotherapy for hematological malignancies or organ-transplant patients , and it has high morbidity and mortality rates . Its incidence has been estimated at around 10 % - 14 %, and the mortality rates may be as high as 27 % - 60 %, despite antifungal therapy . 1 , 2
Cardiac invasive fungal infection is difficult to prove premortem and has an especially high mortality rate . In the case of Aspergillus endocarditis , the mortality rate reaches 96 % if the patient is treated by medication alone , and 68 % even if surgical resection is performed . 3-6 Aspergillus accounts for 24 – 28 % of all cases of fungal endocarditis . 7 There are four different types of manifestations of cardiac aspergillosis described in literature . 8-10 Three of these types are listed as intracavitary mass , myocardial abscess , and endocarditis ; all of these were seen in our case . This is a very rare scenario and , to the best of our knowledge , so many different manifestations of cardiac aspergillosis in a single patient has only once been previously reported in literature . 11 The fourth variety includes embolization of aspergillus into the coronary arteries , which can lead to a myocardial infarction . The clinical diagnosis of Aspergillus endocarditis is usually challenging due to its non-specific presentations , and it is rarely isolated from blood cultures . A high level of clinical suspicion is needed for early diagnosis . 12
References
1 . P . Eggimann , J . C . Chevrolet , M . Starobinski , et al ., “ Primary Invasive Aspergillosis of the Digestive Tract : Report of Two Cases and Review of the Literature ,” Infection , Vol . 34 , No . 6 , 2006 , pp . 333-338 .
2 . L . Pagano , M . Caira , A . Candoni , et al ., “ Invasive Aspergillosis in Patients with Acute Myeloid Leukemia : A SEI- FEM-2008 Registry Study ,” Haematologica , Vol . 95 , No . 4 , 2010 , pp . 644- 650 .
3 . H . Kume , T . Yamazaki , M . Abe , H . Tanuma , M . Okudaira and I . Okayasu , “ Increase in Aspergillosis and Severe Mycotic Infection in Patients with Leukemia and MDS : Comparison of the Data from the Annual of the Pathological Autopsy Cases in Japan in 1989 , 1993 and 1997 ,” Pathology International , Vol . 53 , No . 11 , 2003 , pp . 744-750 . http :// dx . doi . org / 10.1046 / j . 1440-1827.2003.01548 . x
4 . P . Nenoff , C . Kliem , M . Mittag , L . C . Horn , D . Niederwieser and U . F . Haustein , “ Secondary Cutaneous Aspergillosis Due to Aspergillus Flavus in an Acute Myeloid Leukaemia Patient Following Stem Cell Transplantation ,” European Journal of Dermatology , Vol . 12 , No . 1 , 2002 , pp . 93-98 .
5 . T . Yamazaki , H . Kume , S . Murase , E . Yamashita and M . Arisawa , “ Epidemiology of Visceral Mycoses : Analysis of Data in Annual of the Pathological Autopsy Cases in Japan ,” Journal of Clinical Microbiology , Vol . 37 , No . 6 , 1999 , pp . 1732-1738 .
6 . A . S . Kalokhe , N . Rouphael , M . F . El Chami , K . A . Workowski , G . Ganesh and J . T . Jacob , “ Aspergillus Endocarditis : A Review of the Literature ,” International Journal of Infectious Diseases , Vol . 14 , No . 12 , 2010 , pp . e1040-e1047 .
7 . Meshaal MS , Labib D , Said K , Hosny M , Hassan M , Abd Al Aziz S , et al . Aspergillus endocarditis : Diagnostic criteria and predictors of outcome , A retrospective cohort study . PLoS One 2018 ; 13 : e0201459 .
8 . GP Bodey , S Vartivarian . Aspergillosis . Eur J Clin Microbiol Infect Dis . 1989 ; 8:413 – 437 .
9 . P Vaideeswar . Aspergillus pancarditis manifesting as hospital-acquired infection : report of two cases and review of literature . Cardiovasc Pathol . 2010 ; 19 : e253 – e257 .
For more references , email ams @ arkmed . org .
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