eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology

Endocarditis, Fungal: Differential Diagnoses & Workup

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
Contributor Information and Disclosures

Updated: Feb 2, 2009

Differential Diagnoses

Apnea of Prematurity
Myocarditis, Viral
Bacteremia
Neonatal Sepsis
Candidiasis
Outflow Obstructions
Cardiac Tumors
Partial Anomalous Pulmonary Venous Connection
Coarctation of the Aorta
Patent Ductus Arteriosus
Endocarditis, Bacterial
Pericardial Effusion, Malignant
Fever Without a Focus
Pericarditis, Bacterial
Heart Failure, Congestive
Pericarditis, Constrictive
Hospital-Acquired Infections
Pericarditis, Viral
Hypoplastic Left Heart Syndrome
Pulmonary Hypertension, Persistent-Newborn
Infections of the Lung, Pleura and Mediastinum: Surgical Perspective
Respiratory Distress Syndrome
Interrupted Aortic Arch
Rheumatic Heart Disease
Myocardial Infarction in Childhood
Sepsis
Myocarditis, Nonviral
Sinus of Valsalva Aneurysm

Other Problems to Be Considered

Intracardiac thrombus
Postoperative cardiac infection
Postoperative wound infection
Pulmonary hypertension
Congenital heart disease

Workup

Laboratory Studies

  • In fungal endocarditis (FE), blood cultures may be persistently positive despite therapy, especially with Candida infection. However, culture is often negative; less than one half of candidal endocarditis cases yield positive blood cultures, and other causative organisms are even less frequently identified in blood.
  • Culture of urine, sputum, cerebrospinal fluid, synovial fluid, lymph node, and/or bone marrow may offer the only evidence of systemic fungal infection.
  • The CBC count may reveal leukocytosis with or without a left shift. Thrombocytopenia may be seen with fungal infections in general in the neonate.
  • Erythrocyte sedimentation rates and/or C-reactive protein levels may be elevated, although this is unusual in neonates.
  • Urinalysis may demonstrate hematuria, proteinuria, and/or casts.
  • Urine for Histoplasma antigen may be positive.

Imaging Studies

  • Chest radiography
    • Chest radiography may reveal cardiomegaly.
    • Chest radiography may indicate embolic pulmonary infiltrates or pleural effusions.
  • Echocardiography
    • Transthoracic echocardiography is less sensitive than transesophageal echocardiography but is also less invasive.
    • Vegetations and intracardiac thrombi are the most common types but are still rare.
    • Echocardiography may demonstrate pericardial effusion.
    • Normal valves are rarely involved.
    • Echocardiography may suggest myocardial abscesses.
    • Echocardiography may demonstrate associated myocarditis or pericarditis.
  • MRI is particularly useful in identifying ring abscesses.

Other Tests

  • Fungal smears and cultures of operative specimens
  • Electrocardiography is usually nonspecific, although it may demonstrate supraventricular arrhythmias, QRS changes, and/or marked T-wave changes, particularly with myocarditis.

Procedures

  • Cardiac catheterization
    • Catheterization may reveal vegetations, thrombi, or underlying cardiac abnormalities.
    • It should be performed with care in the context of active infection.
    • Postcatheterization precautions include hemorrhage, vascular disruption after balloon dilation, pain, nausea and vomiting, and arterial or venous obstruction from thrombosis or spasm.
    • Complications may include rupture of blood vessel, tachyarrhythmias, bradyarrhythmias, and vascular occlusion.
  • Contrast-enhanced central venous catheter (CVC) injection studies may reveal a catheter-associated thrombus.

Histologic Findings

  • Biopsy or operative specimens should be cultured and special stains should be used to reveal acute and chronic inflammation and/or fungal elements.

More on Endocarditis, Fungal

Overview: Endocarditis, Fungal
Differential Diagnoses & Workup: Endocarditis, Fungal
Treatment & Medication: Endocarditis, Fungal
Follow-up: Endocarditis, Fungal
References
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References

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Further Reading

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Keywords

fungal endocarditis, FE, arthritis, Aspergillus, bacterial endocarditis, Blastomyces dermatitidis, Candida, candidal endocarditis, candidal infection, cardiac infection, central hyperalimentation, CHA, Coccidioides immitis, Cryptococcus neoformans, disseminated candidal infection, fever, fungal infection, Fusarium, heart murmur, Histoplasma capsulatum, infectious endocarditis, Janeway lesions, Mucor, neonatal sepsis, Osler nodes, overwhelming infection, petechiae, Pseudallescheria boydii, Roth spots, splenomegaly, splinter hemorrhages, superior vena cava syndrome, Torulopsis galbrata, Trichosporon beigelii, weight loss

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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: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Medical Editor

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, Heart Rhythm Society, New York Academy of Sciences, Society for Pediatric Research, Texas Medical Association, and Texas Pediatric Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

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.

CME Editor

Gilbert Herzberg, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College
Gilbert 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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