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Case 112

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A 54-year-old patient seeks medical assistance complaining about lumbar pain, shortness of breath during ordinary activities, palpitations and an 11kg weight loss in the last 6 months. History of pulmonary histoplasmosis in 2008, HIV negative, treated with anfotericin B. At examination, he had palpable right ventricle (RV) on left lower sternal border, as well as an ejective systolic murmur audible on pulmonic area and left lower sternal border. A transthoracic echocardiogram was performed showing a well delimited mass with vesicular aspect on RV, causing valvar stenosis and obstruction of the RV exit. Later, a magnetic resonance (MR) was taken.

Based on the clinical history and on the images provided, which is the most probable diagnosis?

a) Primary cardiac tumor

25%

b) Cardiac metastasis

25%

c) Intracavitary thrombus

25%

d) Fungal endocarditis

25%
   

Comments

- Fungal endocarditis accounts for less than 2% of infective endocarditis cases and it is usually related to patients with cardiomyopathies or valve prosthesis and intravenous drug users.

- Histoplasma endocarditis is usually related to its disseminated infection, more often in imunocompromised patients.

- Hitoplasma sp. is a dimorphic fungus common in central US and in Rio de Janeiro state, Brazil.

- The symptoms of the disseminated infection vary according with the organs compromised. Grastrointestinal tract, skin and central nervous system are the most usually affected.

- The diagnosis of fungal endocarditis is similar to those caused by bacteria, except for a higher number of negative blood cultures.

- Treatment consists in valve replacement and high doses of anfotericin B.

References

- Bhatti S, Vilenski L, Tight R, Smego RA. Histoplasma endocarditis: clinical and mycologic features and outcomes. Journal of Infection (2005) 51, 2–9

- Ledtke C, Rehm S, Fraser T, Shrestha N, Tan C, Rodriguez E, Tomford W, Jain A, Lytle B, Jonhston D, Sabik J, Gordon S, Duin D. Endovascular Infections Caused by Histoplasma capsulatum. Arch Pathol Lab Med—Vol 136, June 2012.

- Kanawaty DS, Stalker MJ, Munt PW. Nonsurgical treatment of Histoplasma endocarditis involving a bioprosthetic valve. Chest. 1991; 99(1):253-256. doi:10.1378/chest.99.1.253.

- Aide MA. Capítulo 4 – Histoplasmose. J. bras. pneumol. vol.35 no.11 São Paulo Nov. 2009

- Sexton DJ. Diagnostic approach to infective endocarditis. In: Basow DS. UpToDate. Waltham: UpToDate; 2013.

- Sexton DJ. Infective endocarditis: Historical and Duke criteria. In: Basow DS. UpToDate. Waltham: UpToDate; 2013.

- Wheat J, Kauffman CA. Pathogenesis and clinical manifestations of disseminated histoplasmosis. In: Basow DS. UpToDate. Waltham: UpToDate; 2013.

Authors

Bárbara de Queiroz e Bragaglia, 4º year medical student at FM-UFMG. E-mail: barbara.bragaglia[arroba]gmail.com

Renato Gomes Campanati, 5º year medical student at FM-UFMG. E-mail: renatocampanati[arroba]yahoo.com.br

Orientation

Graziela Chequer, cardiologist, professor at Medical Clinic Deparment at FM-UFMG. E-mail: grazichequerr[arroba].hotmail.com

Reviewers

Glauber Eliazar, Luanna Monteiro e Viviane Parisotto

Translated by

Bárbara de Queiroz e Bragaglia, 4º year medical student at FM-UFMG. Email: barbara.bragaglia[arroba]gmail.com

Renato Gomes Campanati, 5º year medical student at FM-UFMG. Email: renatocampanati[arroba]yahoo.com.br

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