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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
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  Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 33  |  Issue : 4  |  Page : 588-590
 

Surviving a recurrent Scedosporium prolificans endocarditis : A case report


1 Department of Microbiology, Institute of Critical Care and Anaesthesiology, Medanta - The Medicity, Gurgaon, Haryana, India
2 Department of CTVS, Institute of Critical Care and Anaesthesiology, Medanta - The Medicity, Gurgaon, Haryana, India
3 Institute of Critical Care and Anaesthesiology, Medanta - The Medicity, Gurgaon, Haryana, India

Date of Submission20-Mar-2014
Date of Acceptance11-May-2015
Date of Web Publication16-Oct-2015

Correspondence Address:
S Smita
Department of Microbiology, Institute of Critical Care and Anaesthesiology, Medanta - The Medicity, Gurgaon, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.167322

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 ~ Abstract 

Scedosporium prolificans have been reported to be resistant to all antifungals including the newer azoles and echinocandins. We report an unusual case of repeated S. prolificans infection of the heart valves in an immunocompetent patient.


Keywords: Endocarditis, immunocompetent, recurrent, Scedosporium prolificans, terbinafine, voriconazole


How to cite this article:
Smita S, Sunil S, Amarjeet K, Anil B, Yatin M. Surviving a recurrent Scedosporium prolificans endocarditis : A case report. Indian J Med Microbiol 2015;33:588-90

How to cite this URL:
Smita S, Sunil S, Amarjeet K, Anil B, Yatin M. Surviving a recurrent Scedosporium prolificans endocarditis : A case report. Indian J Med Microbiol [serial online] 2015 [cited 2019 Dec 12];33:588-90. Available from: http://www.ijmm.org/text.asp?2015/33/4/588/167322



 ~ Introduction Top


Scedosporium prolificans is an emerging fungus resembling S. apiospermum and is known to cause a wide spectrum of infections in humans whose severity and prognosis depends on the patient's immune status, extent of infection, and feasibility of surgical debridement.[1] There are many reports of isolation of S. apiospermum from various samples but this is a rare case of isolation of S. prolificans from cardiac valves.[1],[2]


 ~ Case Report Top


A 50-year-old, non-hypertensive, diabetic male was referred to our hospital in November 2012. He had frequent episodes of breathlessness and cough with intermittent fever. Echocardiography done at admission revealed a large echogenic osculating mass attached to the tricuspid valve measuring 23 mm × 20 mm causing severe tricuspid regurgitation. Laboratory parameters sent at the time of admission were within normal limits and blood was sent for fungal culture.

Patient had undergone permanent pacemaker implantation in October 2009 which was upgraded to cardiac resynchronisation therapy defibrillator in October 2011. Since January 2012, the patient started to have frequent episodes of fever and was diagnosed as having device related tricuspid valve endocarditis. He underwent tricuspid valve replacement in September 2012. Culture of the valve tissue grew S. prolificans. Patient was put on liposomal amphotericin B for 3 weeks and discharged on a combination of posaconazole and voriconazole.

Epicardial lead implantation and tricuspid valve replacement were done within 2 weeks of admission to our hospital [Figure 1]. Direct microscopy of the valve tissue showed hyaline septate hyphae and culture grew S. prolificans both from the valve tissue and blood culture. Identification of the isolate was done based on macroscopic and microscopic features [Figure 2]. Although no interpretive breakpoints exist for Scedosporium, in vitrodrug sensitivity was done by broth microdilution technique using Sensititre YeastOne (TREK Diagnostic systems USA). It has a positive control well without any antifungals, which should grow around 50–500 colonies after incubation to check the correct inoculum. Moreover, quality control was performed with reference strain of Candida parapsilosis (ATCC 22019). The isolate was found to be resistant to all the antifungals tested including echinocandins, fluconazole, voriconazole, itraconazole, posaconazole, flucytosine, and amphotericin B. Patient was Continued on voriconazole, but terbinafine was added considering the fact that it was a case of relapse. Patient was discharged on day 19 with advice to continue voriconazole 400 mg twice daily and terbinafine 250 mg once daily for 9 months and a follow-up visit at 3 months.
Figure 1: Large tricuspid valve vegetation at open heart surgery

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Figure 2: Lectophenol cotton blue preparation of the colony showing inflated conidiophores bearing single-celled and small clusters of conidia, which are characteristic of Scedosporium prolificans

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Patient was readmitted to our hospital in May 2013 for medical management of diabetes, left bundle branch block and left ventricular dysfunction. He underwent pacemaker implantation and was discharged in a stable condition. During this entire period he was on antifungals as prescribed earlier except the voriconazole dose, which was reduced to 150 mg twice daily.

Patient was readmitted in October 2013 with high-grade fever and breathlessness. Examination of the chest revealed bilateral ronchi. Blood was sent for fungal culture. Echocardiography revealed a large mobile echogenic mass attached to prosthetic leaflets causing significant left ventricular outflow obstruction. Random blood sugar was 260 mg/dl and paired blood culture grew S. prolificans on the 4th day of incubation. Patient had received antifungals for 9 months and there was a gap of 2 months during which he was not on any antifungal therapy. Voriconazole 200 mg 12 hourly and terbinafine 250 mg OD was restarted. Patient underwent re-do tricuspid valve replacement and pacemaker lead extraction in November 2013. Valve tissue and blood culture sent for fungal culture grew S. prolificans. Patient improved clinically and was discharged with advice to continue antifungal therapy. He is under regular follow-up and subsequent echocardiography studies done till February 2014 is free from vegetations.


 ~ Discussion Top


Reported risk factors to scedosporiosis were malignancy, cystic fibrosis, and solid organ transplantation.[3],[4] Our patient is immunocompetent and the source of infection is unknown. He may have got infected through the pacemaker guide wires. S. prolificans was isolated from both his blood and valve cultures both the times he was admitted in our hospital. Uncontrolled blood sugar levels may have contributed to the dissemination of the fungus.

Spectrum of infections reported due to Scedosporium spp. include skin and soft tissue, pulmonary, endophthalmitis, peritonitis, osteoarticular, and disseminated disease.[2],[3] In a PubMed search of published cases, we could not find any report of isolation of S. prolificans from cardiac valves. Clinical infections due to Scedosporium spp. are difficult to treat and frequently fatal.[4] The overall reported mortality is around 47–54% and in patients with disseminated disease, it is around 87.5%.[3],[4]S. prolificans is reported to be more virulent than S. apiospermum and infection in immunocompromised patients represent a life-threatening disease with high mortality.[3],[5] The outcome of our patient so far is good in spite of three valve replacements in the last 2 years.

For S. prolificans the median minimum inhibitory concentrations (MICs) were reported to be higher than 8 g/ml for most antifungal drugs.[4],[5] Despite the high in vitro MICs or absence of in vitro antifungal activity to various antifungals synergistic activity have been reported between few antifungals suggesting that a combination therapy may be more effective than monotherapy. The synergistic interaction can be explained due to mechanisms of action of the antifungal groups blocking the different steps in ergosterol synthesis. In a study, the combination of terbinafine with azoles resulted in synergy for more than 85% of the isolates tested, reducing the MICs for more than 16 times at clinically achievable concentrations.[4] Use of other in vitro combinations such as azoles + echinocandins, amphotericin B + pentamidine, voriconazole + posaconazole, and voriconazole + amphotericin B + micafungin have also been reported.[4],[5]

Our patient was treated with a combination of voriconazole and terbinafine. Success with similar combinations have been reported in cases of osteomyelitis, brain infection and bone marrow recipient.[5],[6],[7] Therapy should usually be continued for a long duration and in most cases for a lifetime. Our patient must have developed a relapse when he stopped taking antifungals for about 2 months.

Scedosporium prolificans is an emerging multiresistant fungal pathogen that may cause a rapidly fatal disseminated infection in neutropenic hosts. There are variable antifungal sensitivity patterns amongst different isolates. S. apiospermum seems to be more susceptible to systemic antifungal agents as compared to S. prolificans therefore identification up to the species level is imperative for targeted antifungal therapy.[1],[4],[5] Moreover, mycosis due to this pathogen underscores the urgent need for newer antifungal agents.

 
 ~ References Top

1.
Foo H, Ooi SY, Giles R, Jones P. Scedosporium apiospermum pacemaker endocarditis. Int J Cardiol 2009;131:e81-2.  Back to cited text no. 1
[PUBMED]    
2.
Verghese S, Padmaja P, Chellamma MT, Leelavathy S, Nayar P. Prosthetic valve endocarditis caused by Scedosporium apiospermum. Indian J Med Microbiol 2005;23:264-6.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Kubak BM, Huprikar SS, AST Infectious Diseases Community of Practice. Emerging and rare fungal infections in solid organ transplant recipients. Am J Transplant 2009;9 Suppl 4:S208-26.  Back to cited text no. 3
    
4.
Cortez KJ, Roilides E, Quiroz-Telles F, Meletiadis J, Antachopoulos C, Knudsen T, et al. Infections caused by Scedosporium spp. Clin Microbiol Rev 2008;21:157-97.  Back to cited text no. 4
    
5.
Lackner M, de Hoog GS, Verweij PE, Najafzadeh MJ, Curfs-Breuker I, Klaassen CH, et al. Species-specific antifungal susceptibility patterns of Scedosporium and Pseudallescheria species. Antimicrob Agents Chemother 2012;56:2635-42.  Back to cited text no. 5
    
6.
Bhat SV, Paterson DL, Rinaldi MG, Veldkamp PJ. Scedosporium prolificans brain abscess in a patient with chronic granulomatous disease: Successful combination therapy with voriconazole and terbinafine. Scand J Infect Dis 2007;39:87-90.  Back to cited text no. 6
    
7.
Howden BP, Slavin MA, Schwarer AP, Mijch AM. Successful control of disseminated Scedosporium prolificans infection with a combination of voriconazole and terbinafine. Eur J Clin Microbiol Infect Dis 2003;22:111-3.  Back to cited text no. 7
    


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  [Figure 1], [Figure 2]



 

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