Pediatric Fungal Endocarditis

Updated: Mar 09, 2015
  • Author: Sandy N Shah, DO, MBA, FACC, FACP, FACOI; Chief Editor: Syamasundar Rao Patnana, MD  more...
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Overview

Background

Fungal endocarditis (FE) is a rare infection in pediatrics. Its incidence is increasing because more neonates are in intensive care units (ICUs), are undergoing cardiac surgical procedures, and are receiving hyperalimentation (CHA).

Fungal endocarditis rarely affects native valves. Rather, it occurs most frequently in neonates as part of a disseminated fungal infection,in patients following cardiac surgery, and in those who develop an intracardiac thrombus or valvular injury due to the presence of 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

In pediatrics, one fourth of fungal endocarditis cases have systemic candidal infection with cardiac involvement. These usually occur as a right-sided intracardiac thrombus at the site of valvular injury due to the presence of a central venous catheter (CVC).

Fungal endocarditis may complicate intracardiac surgery as well as complicate intrathoracic or systemic fungal infection 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

Prognosis is improving because of advances in intensive and operative care, but the survival rate remains less than 25%.

The mortality rate remains 75-90% because of the 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.

Complications

The most common complications in survivors are associated with embolic phenomena, postoperative issues, and underlying or predisposing conditions.

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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