What is Fungal Endocarditis?

Endocarditis is a condition where the innermost layer of the heart, the endocardium, becomes inflamed. This inflammation can occur due to an infectious agent like bacteria or a non-infectious cause. Fungal endocarditis is a less common type of this condition, but it can seriously affect a person’s health and has a poor outlook.

This illness can affect different parts of the heart. It can present as inflammation on a heart valve that was already part of the body (native valve endocarditis) or a heart valve that has been surgically inserted (prosthetic valve endocarditis). The disease can also affect the surface of the endocardium or be associated with a cardiac device implanted in the body.

Diagnosing fungal endocarditis can be difficult. As a result, doctors need to be suspicious of this condition to make a correct diagnosis.

What Causes Fungal Endocarditis?

Fungal endocarditis is a type of heart infection caused by fungi. The most common type of fungus responsible for this infection is Candida, especially one variety known as C. albicans. However, there are other types of Candida that can cause this infection, such as C. parapsilosis, C. tropicalis, and C. glabrata. Another common type of fungus causing this infection is Aspergillus, including A. flavus, A. fumigatus, and A. niger. This fungus is often found in artificial heart valves.

There are also other fungi, including Histoplasma, Cryptococcus neoformans, Trichophyton, Microsporum, Fusarium, Paecilomyces, and Pseudallescheria boydii, that can lead to fungal endocarditis. Children can also get this infection, and the fungi responsible are similar to those in adults. For kids, Candida infections become less common and Aspergillus infections become more common as they grow older, up until they reach 19 years of age.

There are certain factors that increase the risk of getting fungal endocarditis. These include previous open-heart surgery or placement of artificial heart structures, having a central line (a long, thin, flexible tube that’s put into a large vein in your body), long-term antibiotic therapy, drug use, congenital heart disorders (problems with the heart’s structure and function that are present at birth), and weakened immune system, possibly due to prolonged use of corticosteroids (medicines that reduce inflammation).

Most often, fungal endocarditis occurs in artificial heart valves.

Risk Factors and Frequency for Fungal Endocarditis

Fungal endocarditis is not common in healthy individuals and usually affects people who have weakened immune systems. This can be from intravenous drug use, long-term use of antibiotics, or being on parenteral nutrition (receiving nutrients directly into their blood). Those with artificial heart valves or who have undergone heart surgery have an increased chance of getting fungal endocarditis. Fungal endocarditis can also occur in organ transplant recipients who take drugs to suppress the immune system, patients with a condition called myelodysplastic syndrome, and patients who are on long-term corticosteroids and cytotoxic drugs.

Certain Candida species are normally found in the gastrointestinal tract, lower genital tract, and oral cavity. These typically don’t cause issues in people with healthy immune systems. However, the risk of infection with Candida, known as candidiasis, can increase dramatically in individuals whose immune systems are compromised for various reasons.

Aspergillus spp. are types of fungi that are found everywhere in the environment. They can present a risk during building renovations, including in hospitals, if they get into the air conditioning system. This is because Aspergillus can commonly be spread through the air. It’s less common, but Aspergillus can also spread from an existing infection within the thoracic cavity (the part of the body between the neck and the abdomen), through venous access devices (tubes that are placed into a vein to give treatment), or from contamination of artificial heart valves.

Signs and Symptoms of Fungal Endocarditis

Fungal endocarditis, a type of heart infection, can often be hard to tell apart from bacterial endocarditis when a patient first goes to the doctor. Usually, fungal endocarditis gradually develops over time. Fever is by far the most common symptom among patients with this condition, and it typically lasts more than two weeks. The fever may be accompanied by chills, sweating, and tiredness. Patients might also notice a new heart murmur, a change in a former heart murmur, or some other new sound related to the heartbeat.

  • Fever
  • Chills
  • Sweating
  • Tiredness
  • New or changed heart murmur

Another sign of fungal endocarditis is when pieces of the infection break off and travel through the bloodstream to other parts of the body. This can cause symptoms depending on where these bits of infection lodge and block blood flow – for example, in the limbs, brain, lungs, kidneys, or gut.

  • Breathing problems if the pieces of infection travel to the lungs
  • Sharp chest pain that gets worse when you breathe in
  • Coughing
  • Coughing up blood
  • Sudden, severe tummy pain if the bits of infection block blood flow to the gut

If the infection damages the heart valves, the patient could experience symptoms of heart failure. Other symptoms of fungal endocarditis can include weight loss, changes in the shape of the fingers and nails, a rash of red spots, an enlarged spleen, low blood pressure, severe infection throughout the body, and even death. It’s not common, but sometimes there may be signs on the skin caused by the particular fungus causing the infection, such as large nodules in the case of a yeast called Candida.

  • Weight loss
  • Changes to fingers and nails
  • Rash of red spots
  • Enlarged spleen
  • Low blood pressure
  • Skin nodules caused by a yeast infection (rare)

Testing for Fungal Endocarditis

Fungal endocarditis is a severe heart infection that can cause sickness or even death. It’s important to catch this illness as soon as possible to provide proper medication and consider necessary surgical procedures. However, diagnosing it can be tricky. Blood tests often fail to confirm the presence of the disease; in fact, they only detect it less than half of the time.

One way doctors try to detect this disease is by processing and studying your blood samples. They can sometimes boost the chances of spotting the disease this way. Procedures to identify mold infections aren’t as effective as those for yeast infections. But, these tests can be complex and slow.

Alternatively, doctors can conduct rapid non-test-tube tests to check for a fungal infection in your blood. For instance, they might use a substance from the cell walls of a type of yeast, Candida. Its antigen and antibody have been found to correctly spot and mark the presence of infection 83% and 86% of the time, respectively. There’s another type of fungal substance called 1,3 b-D-glucan. It has an accuracy rate of around 70% in detecting the presence of the disease, and 87.1% in confirming non-existence of the disease. Furthermore, if your doctor suspects the illness is caused by a fungus called Aspergillus, they might also look for galactomannan — another fungal substance — in your blood.

If the doctors are unable to confirm the disease with the mentioned methods, they may also look for tissue changes under a microscope from a removed heart valve, clotted blood that has travelled from the heart, or sores on your body. Another quicker method uses a technique called polymerase chain reaction (PCR). This method can spot the genetic material of fungus in your blood or removed heart valves, providing a faster diagnosis.

In addition, doctors may use an echo scan, a sort of ultrasound for the heart. It helps to visualize the heart and the way it functions. This can sometimes aid in diagnosing fungal endocarditis as the scan reveals disease-specific signs like unusually large lesions, mostly on the left side of the heart (though both sides are often affected in patients with weakened immune systems). It may also reveal the infection isn’t limited to the valves, or spot pus-filled pockets (abscesses) in the area around the valve. Trans-esophageal echo scans, performed from within the food pipe, provide better specificity and sensitivity in diagnosing the illness compared to those performed from outside the chest, transthoracic echocardiography.

Your doctor might also check for certain changes in your blood. These include high white blood cell count and levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) — signs of inflammation or infection. It’s also common to see low platelet count, especially in newborn patients.

Treatment Options for Fungal Endocarditis

Fungal endocarditis, an infection of the heart’s inner lining or valves caused by fungi, is a serious condition that requires a team-based approach to care. The treatment usually involves two key steps: early surgical removal of the infected natural or artificial heart valve, followed by a lengthy course of antifungal medicine.

For fungal endocarditis caused by a type of fungus called “Candida”, the initial treatment typically includes a specific type of antifungal medication, such as a lipid formulation of amphotericin B, sometimes combined with another medication. Once the patient’s condition stabilizes and follow-up blood tests show no signs of infection, the patient may be prescribed a less potent antifungal medication, such as fluconazole, taken by mouth. If the Candida fungus is not responsive to fluconazole, other oral medications such as voriconazole or posaconazole may be considered.

For patients with infected heart devices like pacemakers and cardiac defibrillators, these devices are usually removed and antifungal treatment is begun. If the patient has a ventricular assist device (a heart pump device) that cannot be taken out, the patient will start on an antifungal treatment and continue to take a less potent medication, such as fluconazole, for as long as the device stays in place.

For endocarditis caused by a fungus called Histoplasma capsulatum, the treatment usually begins with a lipid formulation of amphotericin B followed by oral medication taken for at least 12 months. In cases of Aspergillus endocarditis, another type of fungal infection, a medication called voriconazole is often used for both initial and long-term treatment.

Here are some medical conditions that can cause symptoms like an unknown fever:

  • Fever of unknown origin
  • Sepsis
  • Bacterial endocarditis
  • Myocarditis

What to expect with Fungal Endocarditis

Fungal endocarditis, a type of heart infection, generally has a worse outcome compared to those caused by bacteria. Spotting it early is crucial. Still, even with the best treatment, death rates can range from 10% to 75%. Often, the poor outcome is due to the patient having other health conditions at the same time.

Possible Complications When Diagnosed with Fungal Endocarditis

  • Blockage in the central nervous system
  • Severe, body-wide infection known as sepsis
  • Failure of multiple organs in the body
  • Heart not being able to pump blood efficiently (heart failure)
  • Disturbance in the electrical signals of the heart (conduction block)
Frequently asked questions

Fungal endocarditis is a less common type of condition where the innermost layer of the heart becomes inflamed. It can occur due to an infectious agent like bacteria or a non-infectious cause.

Fungal endocarditis is not common in healthy individuals and usually affects people who have weakened immune systems.

Signs and symptoms of Fungal Endocarditis include: - Fever, which is the most common symptom and typically lasts more than two weeks. - Chills, sweating, and tiredness. - New or changed heart murmur, or some other new sound related to the heartbeat. - Breathing problems if the pieces of infection travel to the lungs. - Sharp chest pain that gets worse when you breathe in. - Coughing and coughing up blood. - Sudden, severe tummy pain if the bits of infection block blood flow to the gut. - Weight loss. - Changes to fingers and nails. - Rash of red spots. - Enlarged spleen. - Low blood pressure. - Skin nodules caused by a yeast infection (rare).

There are certain factors that increase the risk of getting fungal endocarditis, including previous open-heart surgery or placement of artificial heart structures, having a central line, long-term antibiotic therapy, drug use, congenital heart disorders, and weakened immune system.

The other conditions that a doctor needs to rule out when diagnosing Fungal Endocarditis are: - Fever of unknown origin - Sepsis - Bacterial endocarditis - Myocarditis

The types of tests that a doctor may order to properly diagnose Fungal Endocarditis include: - Blood tests to detect the presence of the disease, such as tests for Candida antigen and antibody, 1,3 b-D-glucan, and galactomannan. - Tissue analysis under a microscope from a removed heart valve, clotted blood, or sores on the body. - Polymerase chain reaction (PCR) to spot the genetic material of fungus in the blood or removed heart valves. - Echo scan (ultrasound for the heart) to visualize the heart and identify disease-specific signs. - Blood tests to check for changes such as high white blood cell count, levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and low platelet count.

Fungal endocarditis is typically treated through a two-step approach. The first step involves early surgical removal of the infected natural or artificial heart valve, followed by a lengthy course of antifungal medicine. The specific antifungal medication used depends on the type of fungus causing the infection. For Candida fungus, a lipid formulation of amphotericin B may be used initially, followed by a less potent antifungal medication like fluconazole. For other types of fungi like Histoplasma capsulatum or Aspergillus, different antifungal medications such as voriconazole or posaconazole may be used. In cases where infected heart devices cannot be removed, antifungal treatment is initiated and a less potent medication like fluconazole is continued as long as the device remains in place.

The side effects when treating Fungal Endocarditis may include: - Blockage in the central nervous system - Severe, body-wide infection known as sepsis - Failure of multiple organs in the body - Heart not being able to pump blood efficiently (heart failure) - Disturbance in the electrical signals of the heart (conduction block)

The prognosis for fungal endocarditis is generally poor, with death rates ranging from 10% to 75%. Even with the best treatment, the outcome is often worse compared to endocarditis caused by bacteria. This is partly due to the fact that fungal endocarditis usually affects individuals with weakened immune systems and other underlying health conditions.

Cardiologist.

Join our newsletter

Stay up to date with the latest news and promotions!

"*" indicates required fields

This field is for validation purposes and should be left unchanged.