Use of Multimodality Imaging in Diagnosing Invasive Fungal Diseases of the Heart
Invasive fungal diseases of the heart are rare, frequently fatal causes of cardiac masses. On imaging, they are difficult to distinguish from other entities, such as thrombi or tumors. The combined use of multiple imaging modalities can aid in diagnosis when integrated with clinical data.1 However, no imaging findings are pathognomonic for invasive fungal disease. We report 4 cases of invasive fungal disease of the heart. Two patients had undergone solid organ transplantation, another had myelodysplastic syndrome, and one was an intravenous drug user. Two patients had invasive aspergillosis, one with valvular endocarditis and another with an intramyocardial abscess, whereas 2 patients had mucormycosis and candidiasis, respectively. Although fungal infections do not have robust central perfusion on cardiac magnetic resonance imaging (a feature of many malignant masses), they often demonstrate delayed peripheral enhancement around the mass, a nonspecific feature suggestive of an infectious cause.2
Case 1: Aspergillus Mitral Valve Endocarditis
A 26-year-old woman with cystic fibrosis, status-post bilateral lung transplantation presented with skin lesions and a positive Galactomannan assay concerning for disseminated aspergillosis. She developed new thalamic strokes suggestive of a potential cardioembolic source. Skin biopsies confirmed infection with Aspergillus fumigatus (Figure 1). Imaging is shown. She subsequently underwent mitral valve debridement, resection, and replacement. Pathology of the mitral valve revealed Aspergillus. She had been on treatment for months with voriconazole and micafungin. Despite salvage therapy with posaconazole, she developed an embolic intracerebral hemorrhage and expired.
Case 2: Isolated Pulmonary Valve Mucor Endocarditis
A 60-year-old woman with transfusion-dependent myelodysplastic syndrome with secondary hemochromatosis complicated by iron overload cardiomyopathy presented with malaise, fatigue, and shortness of breath. Echocardiography demonstrated an enlarging cardiac mass concerning for thrombus in the region of the pulmonic valve extending into the main pulmonary artery (Figure 2). The patient underwent pulmonary embolectomy and pulmonic valve debridement. She was treated with liposomal amphotericin B followed by isavuconazole. Shortly, thereafter, she expired from sepsis.
Case 3: An Intramyocardial Aspergillus Abscess in a Post-Transplant Patient
A 65-year-old female presented with chest pain and dyspnea after cardiac transplantation. Various imaging modalities are shown in Figure 3 and demonstrated a right atrial mass. She developed tamponade physiology from compression of her right heart. She underwent debulking of the abscess but had worsening respiratory failure and circulatory collapse.
Case 4: Tricuspid Valve Candida Endocarditis in an Intravenous Drug User
A 33-year-old man with history of intravenous drug use and a past history of enterococcal endocarditis requiring mechanical aortic and bioprosthetic tricuspid valve replacements presented with fevers and a new harsh systolic murmur in the tricuspid position. Echocardiography demonstrated a vegetation on the tricuspid valve (Figure 4). The course was complicated by septic pulmonary emboli with negative blood cultures. Because of severe tricuspid stenosis and extension of the vegetation into the right ventricle, the patient underwent reoperation tricuspid valve replacement with permanent epicardial pacemaker lead placement.
Guest Editor for this article was David A. Bluemke, MD, PhD.
- © 2017 American Heart Association, Inc.
- El Ghannudi S,
- Imperiale A,
- Dégot T,
- Germain P,
- Trinh A,
- Petean R,
- Le Van Quyen P,
- Chenard MP,
- Letscher-Bru V,
- Kessler R,
- Herbrecht R
- Sverdlov AL,
- Taylor K,
- Elkington AG,
- Zeitz CJ,
- Beltrame JF