Pediatric Fungal Endocarditis 

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

Background

Fungal endocarditis (FE) remains a rare infection, although its incidence is increasing because more neonates are in intensive care and more neonates are undergoing cardiac surgical procedures and central hyperalimentation (CHA). It rarely affects native valves and occurs most frequently in neonates as part of a disseminated fungal infection, in patients following cardiac surgery, or in those who develop an intracardiac thrombus or valvular injury due to a central venous catheter (CVC). Fungal endocarditis is often difficult to diagnose because the presentation may be nonspecific and the disease typically occurs in otherwise critically ill patients with confusing clinical pictures.[1]

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Pathophysiology

Approximately one fourth of neonates and children with systemic candidal disease have a demonstrable cardiac lesion. Fungal infection usually occurs in a right-sided intracardiac thrombus or at the site of a valvular injury secondary to a CVC. Fungal endocarditis may also complicate intracardiac surgery or intrathoracic or systemic fungal infection, particularly in those at highest risk.

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Epidemiology

Frequency

International

Fungi cause 0-12% (average 1.1%) of infectious endocarditis cases in children worldwide. Thus, the incidence rate is approximately 1.5-4 cases per 10 million children. Most published series are from the United States and other developed countries. Two thirds of fungal endocarditis is candidal. Among those in the neonatal intensive care unit (NICU), 1% develop disseminated candidal infection. Despite recent rises in frequency, this remains a rare infection, with reported cases numbering less than a few hundred in patients of any age.

Data are too limited to document the incidence of fungal endocarditis in the developing world. As many risk factors for the disease are associated with advanced medical care, a direct relationship between the availability of these technologies and the frequency of this infection is likely present.

Mortality/Morbidity

The mortality rate remains 75-90% because of difficulty in making the diagnosis, lack of effective antifungal antibiotics, need for surgical intervention in most cases, presence of underlying or predisposing conditions, and frequent comorbid conditions in these typically critically ill neonates and children.

Race

No racial predisposition is present.

Sex

A slight male predominance is observed.

Age

Increasingly, the age distribution of cases is bimodal. The number of cases reported is rising in neonates and, gradually with age, in adults in their second decade of life.

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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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