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Fungal Prosthetic Valve Endocarditis

Rare and lethal infective endocarditis on prosthetic heart valves caused by Candida or Aspergillus, requiring valve surgery and prolonged antifungal therapy.

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

References (5)

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Internal Medicine department. Book Appointment →

What is Fungal Prosthetic Valve Endocarditis?

Fungal prosthetic valve endocarditis (PVE) is a rare but devastating form of infective endocarditis caused most often by Candida species (C. albicans, C. parapsilosis, C. glabrata) and less commonly Aspergillus species. It accounts for less than 10% of fungal endocarditis cases and 1–6% of all PVE cases, with in-hospital mortality of 30–50% even with optimal therapy.

Pathogenesis involves intraoperative inoculation, hematogenous seeding from central venous catheters, parenteral nutrition, broad-spectrum antibiotics with subsequent fungal overgrowth, and immunosuppression. Aspergillus PVE is often nosocomial in early postoperative period, while Candida PVE may occur up to a year or longer after surgery. Bulky vegetations cause systemic embolization, perivalvular abscess, valve dehiscence, and conduction abnormalities.

Diagnosis is challenging because blood cultures are often negative for Aspergillus and intermittent for Candida; echocardiography (preferably TEE) reveals large vegetations and complications. Treatment combines emergent valve replacement with prolonged antifungal therapy: echinocandin (caspofungin, micafungin) plus liposomal amphotericin B or fluconazole/voriconazole for Candida; voriconazole or isavuconazole for Aspergillus. Lifelong oral suppression with fluconazole or voriconazole is recommended given the high relapse risk.

Symptoms

Persistent fever despite antibiotics
New or changing heart murmur
Embolic phenomena (stroke, splenic infarct, peripheral emboli)
Heart failure from valve dysfunction
Splenomegaly
Anemia, leukocytosis
Petechiae, splinter hemorrhages
Roth spots, Janeway lesions, Osler nodes (less common in fungal)
Conduction abnormalities (AV block from abscess)
Renal insufficiency from emboli or immune complex glomerulonephritis
Mycotic aneurysm
Septic shock
CNS findings from septic emboli
Persistent fungemia
Indolent presentation with weight loss and fatigue

Risk Factors

Mechanical or bioprosthetic heart valve
Recent cardiac surgery (especially first 6 months)
Central venous catheter
Parenteral nutrition
Prolonged broad-spectrum antibiotics
Immunosuppression (transplant, chemotherapy, HIV)
Diabetes mellitus
Chronic kidney disease on dialysis
Intravenous drug use
Long ICU stay
Mucosal/skin Candida colonization
Hemodialysis access
Prior episode of fungemia
Multivalve replacement
Reoperation for endocarditis

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Persistent fever in patient with prosthetic heart valve
  • Embolic event in valve patient
  • New murmur or worsening valve dysfunction
  • Persistent positive blood cultures despite antibiotics
  • Candidemia in patient with prosthetic valve
  • Aspergillus or fungal isolate from blood
  • Heart failure decompensation in valve patient
  • Conduction abnormalities post valve surgery
  • Splenomegaly with fever
  • Stroke or peripheral embolus in valve patient

Treatment Methods

01
Hospital admission with cardiology and infectious disease consultation
02
Three sets of blood cultures, including extended incubation for fastidious organisms
03
Beta-D-glucan, galactomannan, Candida and Aspergillus PCR
04
Transthoracic echocardiogram followed by transesophageal echocardiography (TEE)
05
Cardiac CT/MRI, PET-CT for paravalvular abscess and embolic burden
06
Empiric echinocandin (caspofungin, micafungin, anidulafungin) for suspected Candida
07
Empiric voriconazole or isavuconazole for suspected Aspergillus
08
Add liposomal amphotericin B in severe disease or echinocandin failure
09
Fluconazole step-down if susceptible Candida
10
Voriconazole long-term for Aspergillus or non-albicans Candida per susceptibility
11
Emergent valve replacement is generally required (relapse and mortality high without surgery)
12
Surgical timing depending on hemodynamic status, embolic risk, and infection control
13
Remove all central venous catheters and indwelling devices
14
Anticoagulation balance: continue if mechanical valve, weigh against intracerebral hemorrhage risk after embolic stroke
15
Lifelong oral suppression therapy with fluconazole or voriconazole
16
Repeat blood cultures every 48-72 hours until negative for at least 2 weeks
17
Echocardiography surveillance during therapy
18
Source control of any colonization (line removal, drainage)
19
Multidisciplinary team: cardiology, cardiac surgery, infectious disease, microbiology
20
Patient education on dental and procedural prophylaxis indefinitely

Which Department to Visit?

You can visit our Enfeksiyon Hastalıkları department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.