- Email: [email protected]
A Fatal Fungus
Ann Thorac Surg 2005;80:723– 4
References 1. Chan P, Ogilby JD, Segal B. Tricuspid valve endocarditis. Am Heart J 1989;117:1140 – 6. 2. Arbulu A, Asfaw I. Tricuspid valvulectomy without prosthetic valve replacement. Ten years of clinical experience. J Thorac Cardiovasc Surg 1981;82:684 –91. 3. Fucci C, Sandrelli L, Pardini A, et al. Improved results with mitral valve repair using new surgical techniques. Eur J Cardiothorac Surg 1995;9:621–7. 4. Alfieri O, De Bonis M, Lapenna E, et al. The “clover technique” as a novel approach for correction of post-traumatic tricuspid regurgitation. J Thorac Cardiovasc Surg 2003;126:75–9.
AHMED ET AL A FATAL FUNGUS
723
right ventricle. Candida famata was isolated from operative specimens and he was treated with aggressive antifungal therapy. We believe that this is the first reported case of mediastinal Candida famata. (Ann Thorac Surg 2005;80:723– 4) © 2005 by The Society of Thoracic Surgeons
N
on-albicans Candida spp. organisms are emerging pathogens, especially in immunocompromised hosts. Candida famata is an unusual cause of infection in humans. Of 1,663 candidemias in one report during 20 years [1] there were no reported cases of fungemia due to C. famata. A 66-year-old man was admitted with a 2-week history of pre-sternal swelling (Fig 1) associated with tiredness and pyrexia. He had a mass that was 4 ⫻ 4 cm, fluctuant, nonpulsatile, and appeared to be fixed to deeper structures. Preceding this he had a gradual unexplained 8-month long weight loss. He had non-Hodgkin’s lymphoma, which was successfully treated with chemotherapy in 1993. This had been in complete remission since then. In 1997, the patient had undergone coronary artery bypass grafting and also pericardiectomy for calcific constrictive pericarditis at another institution. His postoperative course at that time had been complicated by open cardiac massage. During the same hospital admission he had plastic surgical reconstruction of his chest wall using pectoral muscle flaps. Computed tomography showed a dumbbell shaped collection extending from the subcutaneous area to the anterior mediastinum, but this did not communicate with the heart (Fig 2). The patient underwent surgery to evacuate this collection. With cardiopulmonary bypass on standby, the median sternotomy incision was reopened. A cystic mass was found under the skin. This was incised to reveal a thick-walled cavity filled with pus and clotted blood. At the base of the cavity there was a 1.5 cm hole through the sternum that communicated with a large retrosternal cav-
A Fatal Fungus Ishtiaq M. Ahmed, MRCS, Ajay Gupta, MRCS, Kate Gould, FRCPath, and Stephen C. Clark, FRCS Departments of Cardiothoracic Surgery and Microbiology, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
We report the case of a 66-year-old man who presented with a prodromal type illness and pre-sternal swelling after having coronary artery bypass grafts 4 years earlier. Computed tomography showed that the mass had a retrosternal extension, to join a collection anterior to the Accepted for publication Feb 6, 2004. Address reprint requests to Dr Clark, Department of Cardiothoracic Surgery, Freeman Hospital, Freeman Rd, High Heaton, Newcastle Upon Tyne, NE7 7DN, UK; e-mail: [email protected].
© 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. A lateral view of the pre-sternal swelling. The head of the patient is to the left of the photograph. 0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2004.02.019
FEATURE ARTICLES
Fucci and associates [3] applied to the mitral valve to resolve the central regurgitation. Because the anterior leaflet decreased in size by one-third, valvuloplasty seemed difficult. However the sliding plasty was an effective technique for reattaching the residual valve to the annulus. Annular dilatation was not present because the tricuspid regurgitation occurred acutely and was caused by the vegetation and deformation of the valve. Right ventricular enlargement did not occur so we did not have to use an artificial valvular ring. Because the sliding plasty was applied to the anterior leaflet only the overall valve geometry changed. Regurgitation would not have decreased even if we had performed annuloplasty with an artificial valvular ring. Our method indicated the advantage of not introducing a prosthesis into the infected area. We were concerned with regard to tricuspid stenosis because of the large defect of the anterior leaflet. However central venous pressure after the patient was weaned from CPB was 10 cm H2O and postoperative hepatic failure and peripheral edema did not occur indicating that tricuspid valve function was preserved. Alfieri and associates [4] recently performed valvuloplasty for traumatic tricuspid regurgitation with chordal rupture employing the same leaflet suturing technique we report herein. We believe this technique to be simple and effective not only for traumatic tricuspid regurgitation but also in cases of a defective valve.
CASE REPORT
724
CASE REPORT DRAGANOV ET AL GRAFT RUPTURE DUE TO NECROTIZING VASCULITIS
Ann Thorac Surg 2005;80:724 – 6
limited to removal of an intraocular lens and sac after a cataract extraction, which was complicated by uveitis due to this fungus [3]. Although the patient survived and the fungal infection was eradicated, postoperative visual acuity was severely reduced. We believe that we have described the first documented case of C. famata mediastinitis.
References
Fig 2. A representative cut from the computed tomographic series showing the dumbbell shaped collection extending from the subcutaneous area to the anterior mediastinum. FEATURE ARTICLES
ity containing similar material. The lower part of the sternum was opened with a saw and the cavity was evacuated. After evacuation of the cavity, central venous pressure fell from 30 to 18 mm Hg. The cavity was left open and packed with bacteriocidal agent soaked gauze. Candida famata was isolated from operative specimens and aggressive antifungal therapy was instituted using fluconazole, as well as empirical broad spectrum antibiotics. Unfortunately the patient continued to deteriorate with a septic picture and increasing inotropic requirements. He died 55 days after his admission with multiorgan failure. A postmortem examination showed no evidence of lymphomatous infiltration of the spleen or other lymph nodes. An organizing hematoma with degenerative calcific change was found posterolateral to the right ventricle. One of the previous grafts was found to be occluded, and it was apparent that he had severe native coronary artery disease. There was no evidence of infarct or ischemia.
Comment Fungal infections are usually nosocomial in origin, and usually present in people with predisposing factors such as patients on an immunosuppressive regimen, on intravenous catheters, or who have a malignancy. None of these were present in this patient. Candida famata was first isolated in 1922. It is a saprophyte and usually grows on decomposing organic matter. It can be a contaminant of skin and mucous membranes and has very rarely been reported as a cause of human disease [2]. It has been reported in immunocompromised patients causing peritonitis and endophthalmitis [3] [4]. Of the reported cases, a consistent finding has been its sensitivity to Amphotericin B, imidazole antifungals, triazole antifungals, and flucytosine. It is unlikely that isolation of C. famata has been previously underreported as it readily grows on routine isolation media (horse blood agar). Surgery for infection due to C. famata has been © 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Clancy CJ, Kaufmann CA, Morris A, Nguyen H, Tanwer D, Snydman VL. Correlation of fluconazole MIC and response to therapy for patients with candidemia due to C. albicans and non albicans spp. Clin Infect Dis 1998;27(4):98 –9. 2. Kitch TT, Jacobs MR, McGinnis MR, Appelbaum PC. Ability of rapid yeast plus system to identify 304 clinically significant yeasts within 5 hours. J Clin Microbiol 1996;34:1069 –71. 3. Rao NA, Nerenberg AV, Forster DJ. Torulopsis candida (Candida famata) endophthalmitis simulating Proionibacterium acnes syndrome. Arch Ophthalmol 1991;109:1718 –21. 4. Quindos G, Cabrera F, Arilla MC, et al. Fatal Candida famata peritonitis in a patient undergoing continuous ambulatory peritoneal dialysis who was treated with fluonazole. Clin Infec Dis 1994;18:658 – 60.
Rupture of a Saphenous Vein Coronary Artery Bypass Graft Due to Aspergillus Necrotizing Vasculitis Jutta Draganov, MD, H. Michael Klein, MD, Ali Ghodsizad, MD, Martin Gehrke, MD, and Emmeran Gams, MD Departments of Anesthesiology, Cardiovascular and Thoracic Surgery, and Pathology, Heinrich-Heine-University, Duesseldorf, Germany
We present the first, unusual case of a lethal mediastinal hemorrhage caused by rupture of a saphenous vein aortic coronary bypass graft due to Aspergillus species necrotizing vasculitis in an immunocompetent patient 18 days after redo coronary artery bypass surgery. The patient had neither signs for mediastinitis nor for another source of Aspergillus infection. (Ann Thorac Surg 2005;80:724 – 6) © 2005 by The Society of Thoracic Surgeons
R
upture of a saphenous vein graft with mediastinal hemorrhage is a rare but highly lethal complication after cardiac surgery. Graft rupture has been reported secondary to mediastinitis, bacterial infection within the wall of the vein, or secondary to trauma from sternal edges or veins eroded by mediastinal drainage tubes. There is no reported case of saphenous vein rupture due to Aspergillus species infection. Endovascular infections with Aspergillus are extremely rare and associated with high mortality rate of more than 80%. Only a few cases of Accepted for publication Feb 6, 2004. Address reprint requests to Dr Klein, Department of Cardiovascular and Thoracic Surgery, Heinrich-Heine-University, Moorenstr 5, Duesseldorf 40225, Germany; e-mail: [email protected].
0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2004.02.064
References 1. Chan P, Ogilby JD, Segal B. Tricuspid valve endocarditis. Am Heart J 1989;117:1140 – 6. 2. Arbulu A, Asfaw I. Tricuspid valvulectomy without prosthetic valve replacement. Ten years of clinical experience. J Thorac Cardiovasc Surg 1981;82:684 –91. 3. Fucci C, Sandrelli L, Pardini A, et al. Improved results with mitral valve repair using new surgical techniques. Eur J Cardiothorac Surg 1995;9:621–7. 4. Alfieri O, De Bonis M, Lapenna E, et al. The “clover technique” as a novel approach for correction of post-traumatic tricuspid regurgitation. J Thorac Cardiovasc Surg 2003;126:75–9.
AHMED ET AL A FATAL FUNGUS
723
right ventricle. Candida famata was isolated from operative specimens and he was treated with aggressive antifungal therapy. We believe that this is the first reported case of mediastinal Candida famata. (Ann Thorac Surg 2005;80:723– 4) © 2005 by The Society of Thoracic Surgeons
N
on-albicans Candida spp. organisms are emerging pathogens, especially in immunocompromised hosts. Candida famata is an unusual cause of infection in humans. Of 1,663 candidemias in one report during 20 years [1] there were no reported cases of fungemia due to C. famata. A 66-year-old man was admitted with a 2-week history of pre-sternal swelling (Fig 1) associated with tiredness and pyrexia. He had a mass that was 4 ⫻ 4 cm, fluctuant, nonpulsatile, and appeared to be fixed to deeper structures. Preceding this he had a gradual unexplained 8-month long weight loss. He had non-Hodgkin’s lymphoma, which was successfully treated with chemotherapy in 1993. This had been in complete remission since then. In 1997, the patient had undergone coronary artery bypass grafting and also pericardiectomy for calcific constrictive pericarditis at another institution. His postoperative course at that time had been complicated by open cardiac massage. During the same hospital admission he had plastic surgical reconstruction of his chest wall using pectoral muscle flaps. Computed tomography showed a dumbbell shaped collection extending from the subcutaneous area to the anterior mediastinum, but this did not communicate with the heart (Fig 2). The patient underwent surgery to evacuate this collection. With cardiopulmonary bypass on standby, the median sternotomy incision was reopened. A cystic mass was found under the skin. This was incised to reveal a thick-walled cavity filled with pus and clotted blood. At the base of the cavity there was a 1.5 cm hole through the sternum that communicated with a large retrosternal cav-
A Fatal Fungus Ishtiaq M. Ahmed, MRCS, Ajay Gupta, MRCS, Kate Gould, FRCPath, and Stephen C. Clark, FRCS Departments of Cardiothoracic Surgery and Microbiology, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
We report the case of a 66-year-old man who presented with a prodromal type illness and pre-sternal swelling after having coronary artery bypass grafts 4 years earlier. Computed tomography showed that the mass had a retrosternal extension, to join a collection anterior to the Accepted for publication Feb 6, 2004. Address reprint requests to Dr Clark, Department of Cardiothoracic Surgery, Freeman Hospital, Freeman Rd, High Heaton, Newcastle Upon Tyne, NE7 7DN, UK; e-mail: [email protected].
© 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. A lateral view of the pre-sternal swelling. The head of the patient is to the left of the photograph. 0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2004.02.019
FEATURE ARTICLES
Fucci and associates [3] applied to the mitral valve to resolve the central regurgitation. Because the anterior leaflet decreased in size by one-third, valvuloplasty seemed difficult. However the sliding plasty was an effective technique for reattaching the residual valve to the annulus. Annular dilatation was not present because the tricuspid regurgitation occurred acutely and was caused by the vegetation and deformation of the valve. Right ventricular enlargement did not occur so we did not have to use an artificial valvular ring. Because the sliding plasty was applied to the anterior leaflet only the overall valve geometry changed. Regurgitation would not have decreased even if we had performed annuloplasty with an artificial valvular ring. Our method indicated the advantage of not introducing a prosthesis into the infected area. We were concerned with regard to tricuspid stenosis because of the large defect of the anterior leaflet. However central venous pressure after the patient was weaned from CPB was 10 cm H2O and postoperative hepatic failure and peripheral edema did not occur indicating that tricuspid valve function was preserved. Alfieri and associates [4] recently performed valvuloplasty for traumatic tricuspid regurgitation with chordal rupture employing the same leaflet suturing technique we report herein. We believe this technique to be simple and effective not only for traumatic tricuspid regurgitation but also in cases of a defective valve.
CASE REPORT
724
CASE REPORT DRAGANOV ET AL GRAFT RUPTURE DUE TO NECROTIZING VASCULITIS
Ann Thorac Surg 2005;80:724 – 6
limited to removal of an intraocular lens and sac after a cataract extraction, which was complicated by uveitis due to this fungus [3]. Although the patient survived and the fungal infection was eradicated, postoperative visual acuity was severely reduced. We believe that we have described the first documented case of C. famata mediastinitis.
References
Fig 2. A representative cut from the computed tomographic series showing the dumbbell shaped collection extending from the subcutaneous area to the anterior mediastinum. FEATURE ARTICLES
ity containing similar material. The lower part of the sternum was opened with a saw and the cavity was evacuated. After evacuation of the cavity, central venous pressure fell from 30 to 18 mm Hg. The cavity was left open and packed with bacteriocidal agent soaked gauze. Candida famata was isolated from operative specimens and aggressive antifungal therapy was instituted using fluconazole, as well as empirical broad spectrum antibiotics. Unfortunately the patient continued to deteriorate with a septic picture and increasing inotropic requirements. He died 55 days after his admission with multiorgan failure. A postmortem examination showed no evidence of lymphomatous infiltration of the spleen or other lymph nodes. An organizing hematoma with degenerative calcific change was found posterolateral to the right ventricle. One of the previous grafts was found to be occluded, and it was apparent that he had severe native coronary artery disease. There was no evidence of infarct or ischemia.
Comment Fungal infections are usually nosocomial in origin, and usually present in people with predisposing factors such as patients on an immunosuppressive regimen, on intravenous catheters, or who have a malignancy. None of these were present in this patient. Candida famata was first isolated in 1922. It is a saprophyte and usually grows on decomposing organic matter. It can be a contaminant of skin and mucous membranes and has very rarely been reported as a cause of human disease [2]. It has been reported in immunocompromised patients causing peritonitis and endophthalmitis [3] [4]. Of the reported cases, a consistent finding has been its sensitivity to Amphotericin B, imidazole antifungals, triazole antifungals, and flucytosine. It is unlikely that isolation of C. famata has been previously underreported as it readily grows on routine isolation media (horse blood agar). Surgery for infection due to C. famata has been © 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Clancy CJ, Kaufmann CA, Morris A, Nguyen H, Tanwer D, Snydman VL. Correlation of fluconazole MIC and response to therapy for patients with candidemia due to C. albicans and non albicans spp. Clin Infect Dis 1998;27(4):98 –9. 2. Kitch TT, Jacobs MR, McGinnis MR, Appelbaum PC. Ability of rapid yeast plus system to identify 304 clinically significant yeasts within 5 hours. J Clin Microbiol 1996;34:1069 –71. 3. Rao NA, Nerenberg AV, Forster DJ. Torulopsis candida (Candida famata) endophthalmitis simulating Proionibacterium acnes syndrome. Arch Ophthalmol 1991;109:1718 –21. 4. Quindos G, Cabrera F, Arilla MC, et al. Fatal Candida famata peritonitis in a patient undergoing continuous ambulatory peritoneal dialysis who was treated with fluonazole. Clin Infec Dis 1994;18:658 – 60.
Rupture of a Saphenous Vein Coronary Artery Bypass Graft Due to Aspergillus Necrotizing Vasculitis Jutta Draganov, MD, H. Michael Klein, MD, Ali Ghodsizad, MD, Martin Gehrke, MD, and Emmeran Gams, MD Departments of Anesthesiology, Cardiovascular and Thoracic Surgery, and Pathology, Heinrich-Heine-University, Duesseldorf, Germany
We present the first, unusual case of a lethal mediastinal hemorrhage caused by rupture of a saphenous vein aortic coronary bypass graft due to Aspergillus species necrotizing vasculitis in an immunocompetent patient 18 days after redo coronary artery bypass surgery. The patient had neither signs for mediastinitis nor for another source of Aspergillus infection. (Ann Thorac Surg 2005;80:724 – 6) © 2005 by The Society of Thoracic Surgeons
R
upture of a saphenous vein graft with mediastinal hemorrhage is a rare but highly lethal complication after cardiac surgery. Graft rupture has been reported secondary to mediastinitis, bacterial infection within the wall of the vein, or secondary to trauma from sternal edges or veins eroded by mediastinal drainage tubes. There is no reported case of saphenous vein rupture due to Aspergillus species infection. Endovascular infections with Aspergillus are extremely rare and associated with high mortality rate of more than 80%. Only a few cases of Accepted for publication Feb 6, 2004. Address reprint requests to Dr Klein, Department of Cardiovascular and Thoracic Surgery, Heinrich-Heine-University, Moorenstr 5, Duesseldorf 40225, Germany; e-mail: [email protected].
0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2004.02.064