Pediatric Fungal Endocarditis Workup

Updated: Dec 21, 2020
  • Author: Sandy N Shah, DO, MBA, FACC, FACP, FACOI; Chief Editor: Syamasundar Rao Patnana, MD  more...
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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.

Polymerase chain reaction (PCR) on blood and/or valve tissue has been described. [14, 12] Non-invasive methods such as PCR may improve detection of the etiologic agent in a timely manner. [12]

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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.

Magnetic resonance imaging

Magnetic resonance imaging is particularly useful in identifying ring abscesses.

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Other Tests

Fungal smears and cultures of operative specimens may be useful.

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

Electrocardiography is usually nonspecific, although it may demonstrate supraventricular arrhythmias, QRS changes, and/or marked T-wave changes, particularly with myocarditis.

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Procedures

Cardiac catheterization

Catheterization may reveal vegetations, thrombi, or underlying cardiac abnormalities. However, it is not required for diagnosis; transthoracic, and when necessary transesophageal, echocardiography may be adequate for the diagnosis. When needed, it should be performed with care in the context of active infection.

Postcatheterization complications 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

Contrast-enhanced central venous catheter (CVC) injection studies may reveal a catheter-associated thrombus.

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