Pediatric Fungal Endocarditis Clinical Presentation

  • Author: Robert W Tolan Jr, MD; Chief Editor: Steven R Neish, MD, SM   more...
 
Updated: Jan 9, 2012
 

History

Patients with fungal endocarditis (FE) may have a history of cardiac surgery complicated by symptoms of infection, such as fever, deteriorating cardiac status, embolic phenomena, and dehiscence.

History of intrathoracic or systemic fungal infection with spread to the heart is rare.

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Physical

On rare occasions, fungal endocarditis presents as typical bacterial endocarditis, with fever, weight loss, splenomegaly, splinter hemorrhages, Roth spots (pale retinal lesions with surrounding hemorrhage), Osler nodes (painful nodular lesions on the finger and/or toe pads), petechiae, Janeway lesions (painless hemorrhagic plaques on the palms and/or soles), arthritis, and a new or changing heart murmur.

Often, an indwelling central venous catheter (CVC) is present. The use of CVC for central hyperalimentation (CHA) is an additional risk factor.

Occasionally, positive blood culture results or positive culture results of other tissues and fluids (despite negative blood culture results) are the only evidence.

Cardiac involvement, without other symptoms or signs of infection, may be the only clinically apparent feature.

An inflow obstruction (superior vena cava syndrome with cough, hoarseness, dysphagia, and/or a full sensation in the ears) due to an infected thrombus may be the sole manifestation of disease.

In neonates, symptoms are often nonspecific and include apnea and bradycardia, hypothermia, poor perfusion, feeding intolerance, increased ventilatory support, and evidence of septic emboli. Rarely, a new or changing heart murmur is present.

In neonates, Janeway lesions, petechiae, splinter hemorrhages, and evidence of multiple septic emboli have been reported, although Osler nodes and Roth spots have not been reported.

In the postoperative period, patients may have symptoms such as fever, cardiac decompensation, a new or changing heart murmur, evidence of embolic phenomena, and dehiscence.

Superior vena cava syndrome may manifest as hoarseness, swelling of the face, wheezing or stridor, and/or venous engorgement.

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Causes

No particular inheritance patterns are associated with fungal endocarditis.

Causal organisms include the following:

  • Candida species (two thirds of all reported cases)[2]
  • Aspergillus species (particularly in postoperative patients, with spread from systemic and pulmonary infections, and in immunocompromised hosts)[3, 4]
  • Histoplasma capsulatum (causes pericarditis more frequently)
  • Blastomyces dermatitidis, Cryptococcus neoformans,[5] Coccidioides immitis (mostly pericarditis; rarely endocarditis)
  • Mucor species, Torulopsis glabrata, Trichosporon beigelii, Fusarium species (rare)
  • Pseudallescheria boydii (prosthetic valve endocarditis)
  • Scedosporium species[6]

Risk factors include the following:

  • Neonatal period
  • History of cardiac surgery
  • CVC in place
  • CHA
  • Broad-spectrum antibacterial therapy
  • Intravenous drug use
  • Preexisting valvular lesion or injury, such as congenital heart disease, bacterial endocarditis, rheumatic heart disease, prosthetic valve
  • Transient fungemia after bowel surgery
  • Any condition associated with immune compromise

Fungal endocarditis rarely affects native valves.

Fungal endocarditis may spread from intrathoracic (particularly pleural-based) infections.

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Contributor Information and Disclosures
Author

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Specialty Editor Board

Jeffrey Allen Towbin, MD, MSc, FAAP, FACC, FAHA  Professor, Departments of Pediatrics (Cardiology), Cardiovascular Sciences, and Molecular and Human Genetics, Baylor College of Medicine; Chief of Pediatric Cardiology, Foundation Chair in Pediatric Cardiac Research, Texas Children's Hospital

Jeffrey Allen Towbin, MD, MSc, FAAP, FACC, FAHA is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American College of Cardiology, American College of Sports Medicine, American Heart Association, American Medical Association, American Society of Human Genetics, Cardiac Electrophysiology Society, New York Academy of Sciences, Society for Pediatric Research, Texas Medical Association, and Texas Pediatric Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Julian M Stewart, MD, PhD  Associate Chairman of Pediatrics, Director, Center for Hypotension, Westchester Medical Center; Professor of Pediatrics and Physiology, New York Medical College

Julian M Stewart, MD, PhD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Gilbert Z Herzberg, MD  Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College; Consulting Staff, Department of Pediatrics, Sound Shore Medical Center

Gilbert Z Herzberg, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Chief Editor

Steven R Neish, MD, SM  Director of Pediatric Cardiology Fellowship Program, Associate Professor, Department of Pediatrics, Baylor College of Medicine

Steven R Neish, MD, SM is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and American Heart Association

Disclosure: Nothing to disclose.

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Candida albicans vegetation (blue arrow) in the left atrium and attached to the intra-atrial septum in a 24-week estimated gestational age newborn (courtesy of Albert Santos and Dr. Sumekala Nadaraj, New Brunswick, NJ).
Candida albicans vegetation (blue arrow) in the left atrium and attached to the intra-atrial septum in a 24-week estimated gestational age newborn (courtesy of Albert Santos and Dr. Sumekala Nadaraj, New Brunswick, NJ).
 
 
 
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