General malaise, raised inflammatory markers, splinter hemorrhages and Osler nodes. Initially there was a strong suspicion regarding infective endocarditis but initial blood cultures and trans-thoracic echocardiogram were negative. History of aortic valve replacement several months previously.
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Midline sternotomy and bioprosthetic aortic valve replacement.
4.5 cm filling defects within the lumen of the ascending aorta, extending from the aortic valve superiorly. Mural edema seen along anterior aortic root and extending into the anterior mediastinum, with 3 cm max diameter walled off collection seen adjacent (to right of midline).
Ground glass changes and interstitial thickening in right upper lobe presumed reactive.
Right pleural effusion.
Several prominent but subcentimeter mediastinal lymph nodes.
No other significant findings.
Large lobular filling defects seen on CT in keeping with vegetations of infective endocarditis. These were not seen on transthoracic echocardiogram (possibly due to metal artefact), but were later also demonstrated on transesophageal echocardiogram.
Blood cultures were initially negative but repeated cultures and further testing later demonstrated Aspergillus galactomannan. Impression was that this was therefore likely a case of fungal endocarditis.
Fungal endocarditis is uncommon but carries a poor prognosis. Vegetations are often large at diagnosis and rates of embolization are very high 1. It is not only difficult to diagnose but also difficult to treat.
- 1. Kalokhe AS, Rouphael N, El Chami MF, Workowski KA, Ganesh G, Jacob JT. Aspergillus endocarditis: a review of the literature. (2010) International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases. 14 (12): e1040-7. doi:10.1016/j.ijid.2010.08.005 - Pubmed