SESSION TITLE: Infectious Disease Cases IV
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Tuesday, October 29, 2013 at 07:30 AM - 09:00 AM
INTRODUCTION: Massive pulmonary embolus is generally the product of clotting cascade processes. Other masses may rarely embolize to the pulmonary circulation. We present the first reported case of a candida mycetoma causing massive pulmonary embolism with subsequent cure.
CASE PRESENTATION: An 84 year old patient with a history of automatic implantable cardiac defibrillator (AICD) placement presented with complaints of malaise and fever was found to have Candida albicans bacteremia. A transthoracic echocardiogram (TTE) demonstrated a pedunculated, mobile mass extending 3.5 cm into the ventricular cavity and prolapsing during diastole through a severely regurgitant tricuspid valve into the right atrium. The AICD and intraventricular leads were removed; intraoperative transesophageal echo showed the vegetation continuing to adhere to the tricuspid valve after lead removal. One day after surgery the patient developed respiratory failure and shock and was intubated. Repeat TTE did not identify the vegetation and a subsequent CT chest revealed embolization into the right main pulmonary artery. Pulmonary artery arterioplasty and tricuspid valve replacement were performed, with successful retrieval of the embolic mycetoma. The patient recovered from her shock. She continued to receive antifungal therapy and was discharged to subacute care in improved condition on her 32nd day of hospitalization.
DISCUSSION: Candidal intracardiac lead infection is relatively rare though steadily increasing in frequency (1). Symptomatic embolism of a mycetoma cured with retrieval via arterioplasty has not previously been reported. Given the increasing incidence of both implantable medical devices and candidal infection, this phenomenon will likely become more common. While embolic candidal mycetoma is unique, some precedent for treatment exists from the treatment of atrial myxomas. Pulmonary embolectomy to retrieve embolic myxomas has previously proven successful (2,3). Surgical management should be considered in the case of massive emboli suspected to consist of material not amenable to fibrinolysis.
CONCLUSIONS: While the treatment for pulmonary embolus generally relies on anticoagulants or thrombolytics, aggregates of other material may require a more direct strategy. Known intracardiac masses at risk for dislodgment should be monitored aggressively and prompt surgical intervention should be considered in the case of embolism causing shock.
Reference #1: Halawa A, Henry PD, Sarubbi FA. Candida endocarditis associated with cardiac rhythm management devices: review with current treatment guidelines. Mycoses. 2011 Jul;54(4):e168-74. doi: 10.1111/j.1439-0507.2010.01866.x. Epub 2010 Mar 22.
Reference #2: Battellini R, Bossert T, Areta M, Navia D. Successful surgical treatment of a right atrial myxoma complicated by pulmonary embolism. Interact Cardiovasc Thorac Surg. 2003 Dec;2(4):555-7.
DISCLOSURE: The following authors have nothing to disclose: Charanpal Singh, Luke White, David Kelley
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