micafungin and Endocarditis

Infection of implanted cardiac devices has a low rate of occurrence. Fungal infections of such devices represent an atypical phenomenon, associated with high mortality. Both medical and surgical therapies are recommended for a successful outcome. A 60-year-old woman with past medical history of heart failure with reduced ejection fraction, implantable cardioverter-defibrillator (ICD) placement, sarcoidosis and diabetes presented with fevers and atypical pleuritic chest pain. Transthoracic echocardiogram revealed a highly mobile 2.09 cm by 4.49 cm mass associated with the ICD wire. Blood cultures were positive for Candida albicans. The patient underwent sternotomy for removal. The vegetation was 4 cm by 2 cm by 2 cm in size, attached to the right ventricle without interference with the tricuspid valve. The patient was treated with micafungin for 2 weeks and then fluconazole for 6 weeks. In this case report, we describe the rare infection of an ICD lead with C. albicans, in the form of a fungal ball. This is the 18th reported case of Candida device-related endocarditis and the first reported in a woman. Prior case reports have occurred primarily in pacemaker rather than ICD leads. The vegetation size is also one of the largest that has been reported, measuring 4 cm at its greatest length. As Candida device-related endocarditis is so rare, and as fatality occurs in half of cases, clinical management can only be derived from sporadic case reports. Therefore, the course of this patient's disease care will be a useful adjunct to the current literature for determining treatment and prognosis in similar cases.

Topics: Antifungal Agents; Candida albicans; Candidiasis; Defibrillators, Implantable; Echinocandins; Echocardiography; Endocarditis; Female; Fluconazole; Humans; Lipopeptides; Micafungin; Middle Aged; Prosthesis-Related Infections

We report on the treatment with micafungin of a pacemaker-associated endocarditis due to Candida albicans. Antifungal therapy was able to reduce vegetation size from 5 to 1 cm making possible the transvenous removal of the device without a high risk of pulmonary embolism. Noteworthy, a high micafungin concentration was documented into the lead vegetation (10 μg/g of vegetation tissue) and this may have contributed to the striking size reduction of vegetation.

Topics: Aged; Antifungal Agents; Candida albicans; Echinocandins; Echocardiography; Endocarditis; Female; Humans; Lipopeptides; Micafungin; Microbial Sensitivity Tests; Pacemaker, Artificial; Prostheses and Implants; Treatment Outcome

Topics: Aged, 80 and over; Antifungal Agents; Candida glabrata; Candidiasis; Drug Resistance, Fungal; Echinocandins; Endocarditis; Fluconazole; Heart Valve Prosthesis; Humans; Male; Micafungin; Prosthesis-Related Infections; Recurrence

Topics: Amphotericin B; Antifungal Agents; Aspergillosis; Aspergillus fumigatus; Diagnosis, Differential; Echocardiography; Endocarditis; Fatal Outcome; Female; Heart Atria; Humans; Micafungin; Middle Aged; Myxoma; Voriconazole

Topics: Amphotericin B; Antifungal Agents; Aortic Valve; Burns; Candida tropicalis; Candidemia; Echocardiography; Endocarditis; Heart Valve Prosthesis Implantation; Hospitalization; Humans; Invasive Fungal Infections; Male; Micafungin; Middle Aged; Mitral Valve

Topics: Acute Coronary Syndrome; Antifungal Agents; Aortic Valve Insufficiency; Blood Culture; Candida glabrata; Candidiasis; Coronary Angiography; Diagnosis, Differential; Echinocandins; Echocardiography; Electrocardiography; Endocarditis; Female; Heart Valve Prosthesis Implantation; Humans; Lipopeptides; Micafungin; Middle Aged; Myocardial Infarction; Thrombectomy

Endocarditis caused by Candida dubliniensis is a rare event and limited to few case reports. In this report, the authors present a patient with a history of intravenous drug use and hepatitis C and endocarditis involving a prosthetic aortic valve. Also reviewed are the treatment guidelines for Candida sp. endocarditis.

Topics: Amphotericin B; Antifungal Agents; Candida; Candidiasis; Echinocandins; Endocarditis; Fluconazole; Humans; Lipopeptides; Male; Micafungin; Middle Aged

We report an uncommon but emerging fungal pathogen, Candida kefyr, as a causative agent of infective endocarditis in a patient with a known history of hypertrophic obstructive cardiomyopathy. A 74-year-old woman with diabetes type II, hypertrophic obstructive cardiomyopathy, presented with gross hematuria and abdominal pain. Computed tomography scan revealed a hemorrhagic mass in the superior pole of the right kidney, with a thrombus extending from the ureter to the bladder. She underwent cryotherapy of the renal mass, together with retrograde ureteral stent placement, developed hypotension and respiratory distress, spiked high-grade fever, and had a new pansystolic murmur over the mitral and aortic areas. Urine and blood culture grew C. kefyr. Transthoracic echocardiogram revealed large mitral valve vegetation with moderate regurgitation. Micafungin was started, patient responded, and fungemia cleared. Repeat echocardiogram showed small vegetation, preserved leaflet mobility and mild regurgitation. Patient received 10 days of micafungin, followed by 6 weeks of fluconazole.

Topics: Aged; Antifungal Agents; Candidiasis; Cardiomyopathy, Hypertrophic; Echinocandins; Endocarditis; Female; Fluconazole; Humans; Kidney Neoplasms; Lipopeptides; Micafungin

Diagnosis and treatment of Candida albicans endocarditis can be difficult. We report a case of this rare condition in which a patient on oral fluconazole presented with septic pulmonary emboli without initial echocardiographic evidence of vegetation. Rapid attainment of a tissue diagnosis, along with combined medical surgical treatment proved to be effective for this patient.

Topics: Adolescent; Antifungal Agents; Biopsy; Candidiasis; Cardiovascular Surgical Procedures; Combined Modality Therapy; Echinocandins; Endocarditis; Female; Humans; Lipopeptides; Micafungin; Pulmonary Artery; Pulmonary Embolism; Treatment Outcome; Tricuspid Valve

The in vitro effects of flucytosine (5FC), liposomal amphotericin B (L-AmB), and micafungin (Mica) combinations against two Candida albicans strains that simulated 24-hour-old endocardial vegetations were studied. Mica was superior to 5FC or L-AmB, and the 5FC-L-AmB-Mica combination was superior to all other treatments for one strain but no different from the dual combination of L-AmB-Mica for the other strain.

Topics: Amphotericin B; Antifungal Agents; Biofilms; Candida albicans; Drug Combinations; Echinocandins; Endocarditis; Flucytosine; Humans; Lipopeptides; Micafungin

In vitro pharmacodynamic model (PDM) simulation of serum antifungal concentrations may predict the value of combination antifungal regimens against Candida sp. endocarditis. We investigated the effects of combinations of flucytosine (5FC), micafungin (Mica), and voriconazole (Vor) against Candida-infected human platelet-fibrin clots, used as simulated endocardial vegetations (SEVs). Single clinical bloodstream isolates of Candida albicans, Candida glabrata, Candida parapsilosis, and Candida tropicalis were used. All four isolates were susceptible to 5FC, while C. glabrata was resistant to Vor and C. tropicalis had a paradoxical resistance phenotype to Mica. The SEVs were prepared with an initial inoculum of 1 x 10(6) CFU/g of SEV and added to a PDM, which utilized yeast nitrogen broth-2% glucose and incubation at 35 degrees C and simulated antifungal pharmacokinetic profiles. Fungal densities in the SEVs were determined in quadruplicate over 72 h. Scanning electron microscopy (SEM) was used to evaluate treatment and control SEVs. Vor was the least active single agent against all Candida spp. except for C. parapsilosis, where it was comparable to Mica. In contrast, 5FC was the most active against all Candida spp. except for C. tropicalis, where it was comparable to Mica. The combination of 5FC plus Vor was superior to either agent alone against C. parapsilosis. The combination of Vor plus Mica was inferior to the use of Mica alone against C. tropicalis. The triple combination of 5FC plus Vor plus Mica was no better than single or dual agents against any of the Candida spp. The ultrastructural features of infected SEVs were unique for each Candida sp., with C. parapsilosis in particular manifesting friable biofilm clusters. In general, 5FC and Mica were superior in their rates and extents of fungal burden reduction compared to Vor against Candida-infected SEVs. Evaluation of 5FC and Mica in animal models of Candida endocarditis is warranted.

Topics: Antifungal Agents; Candida; Candida albicans; Candida glabrata; Candida tropicalis; Candidiasis; Drug Resistance, Fungal; Drug Therapy, Combination; Echinocandins; Endocarditis; Flucytosine; Humans; In Vitro Techniques; Lipopeptides; Lipoproteins; Micafungin; Microbial Sensitivity Tests; Microscopy, Electron, Scanning; Models, Biological; Pyrimidines; Triazoles; Voriconazole