Saccharomyces Fungemia

173

SACCHAROMYCES FUNGEMIA the cardiovascular surgeon. The application of both at the same time is. hmH>\·er. unusual. The follmdng is a report of such a case with a one year follow-up. CASE REPoHT

A .54-year-old white woman was seen in cOrL'iultation following cardiac catheterization which doculllented Jlloderately severe mitral stenosis and pulmonary hypertellsion. Although intermittplltly symptomatic for 1:3 tn 14 years, her condition did not hegill to deterinrate significantl:r until fixe months prior to admission. At that time she noted. progressive dyspnea, fati~lIe, and weight loss. Approximately one m.onlh prior to admission, she wa..; hospitalizt'd for congestin" Ilt'art failure {'oincident with a change in heT rhythm to <.\trial fihrillation. Three weeks prior to admission the patient experienced the onst>t of smldt'n numhness, c()ldnes~, and cramping in both lowpr pxtremities dh;tal to the lIppe-r third of the thighs. Since that time she had l>een confined to bed with pain at rest. \Vlwn sel'n, the patil'llt presf'lltl'd as a middlf'-a~l'd. pale. \\'a~tpd whitt' woman sitting in IX'd complaining of pain in both lower extremities. The hlood pressure was 110/60 in hoth arllls and tilt" hl'art ratl' was irregular at 1:20 heat.. per minuh'. Physical findings \"ere charactl'ristic of tidlt mitral stenosis, pulmonary hypertension and atrial fibrillation with pleural t"ffusion. The lowt"r t"xtremities Wt"H:' pulst"lt"ss. cooL and pale. The abdominal aortic pulsation was felt in the midepiga,trium. Trans-lumhar aortogram revealed complete occlusion of the terminal aorta with llssds visualizl'd distal to tIll' common iliac bifurcations. Bilateral transfemoTilI retrograde aortic hifurcation embolectomy with Fogarty catht·ters was ."lIccl'ssflllIy accomplisllPd on August 23. 19G7. \\"ith satbfactory How rl'-estahlislwd to the lower l'xtrl'lIlitil's. open mitral commissllrotomy and left atrial thromlx'domy wert' undertaken thrOllgh a median stt'rnc)toIllY utilizing the ascending aorta for the arterial l)t"rfllsion cannula. Postoperatin·ly. the patient suffered transient disorientation and moderate right pleural effusion. ~ormal sinus rhythm ap}>t-'ared during ('ardiotomy and pl:>rsiskd until discharge on the b,-'nth IX)stopt'ratin' uay at which time atrial fihrillation reappeared despite the early institution of quini. dine prophylaxis. Pedal pulses did not reappear until 48 hOlm postopt'ratioll, although tilt' patient was imlllt'diately relien'd of lower extremity rest pain on awakening from the anesthetic. Six \\'et'ks followin,:! dbchar,:!e. tIlt' patient was re-admitted and successfully c0I1H·rh.·J to normal sinus rhythm hy dirt·ct current countershock. One year postoperation she remains in normal sinus rhythm ha\'ing discontinut'd quinidine six months aftl'r canliow·rsioTl. Although the IlmnllUrS of mitral insufficiency and aortic insufficiency are detectahle, she has rehlmed to .1 functional Class I. The lower extremity pulses through the pedal len-I are now excellent and the patient suffers no discomfort in the legs or feet. X-ray film of the chest ren'als a marke<:l reduction in hl:"art size and clear lung fields.

Two aspects of this case prompt its report: the application of both techniques under a single anesthetic. and the satisfactory accomplishment of retrograde emholectomy six weeks after occlusion of the aortic hifurcation. The status of the lower extremities was so precarious that to proceed with heart-lung bypass (with its altered flow characteris ties ) seemed to pose an uneertain risk to their survival. Relief of the aortic bifurcation occlusion CHEST, VOL. 58, NO.2, AUGUST 1970

was the urgent problem, but this was effected with such lIIWxp(>cted facility that we elected to proceed with definitive surgt'ry on the mitral valve. Disohliteration of the aorto-iliac channels was aecomplished without undue traction on the inflated balloon catheter or apparent intimal injury despite the age of the pathologic process. Several passes were required hefore no further thromboembolic material \\'as recovered and satisfactorY forward flow t'stahlished. The extracted fragmented specimen represented clot in various stages of organization. The common femoral arteries were quite small at surgery reflecting chronic diminution of the inflow. It was of interest to note that pedal pulses were not apparent until -18 hours after resumption of antcgrade flow. Furthermorc. the patient experieneed disturbing dysesthesias in the IPgs and feet that did not disappear until se\'en months following surgery. An extensive organized thrombus was found in the body of the left atrium and tll(' left atrial appendage. This was removed and the left atrial appendag(' ligated at its hase following commissurotomy hy sharp incisions. The opportunity to perform mitral surgery at the time of emboleetomy. we felt. significantly redueed the hazard of recurrent peripheral embolism that would have existed had these two proeedures been staged. Our experienee with this case suggests not only that long delayed retrograde embolectomy is feasible. hut also that the concurrent application of this technique with open mitral repair may be successful in selected instances of rheumatie mitral dis(>ase complicated bv peripheral arterial embolism. Reprint request" Dr. Somerndike. 1125 East 17th SITed. Santa Ana 92701

Saccharomyces Fungemia * Paul D. Stein . .\ I.D.. Alan T. Folkem•.\I.S., mul Keitl. A. ll",.,ka, .\I.D.

Fungal septicemia due to Saccharomyces is described in a patient previousl~' treated with heavy doses of antibiotics for suspected prosthetic valve endocarditis. No previous reports of infection due to Saccharomyces were found in the literature. This report illustrates that patients with prosthetic heart valns may be susceptible to septicemia or endocarditis caused by fungi that are usually nonpathogenic. This is especiall~' true if the patients have received large doses of antibiotics. The fact that this patient survived after treatment with amphotericin Bindicates that medical therap~' may be successful in some patients with prosthetic heart vah'es who have had fungi cultured from the blood. oFrom Creighton Vnivt"rsitv School of \fedicine. Omaha, :\dlraska. and LTni\"ersity ,;f Oklahoma School of ~kdicine, Oklahoma City.

174

STEIN ET AL

Endocarditis is a serious complication of prosthetic valve replacement and in the absence of antistaphylococcal propylaxis causes 3.3 percent of fatalities occurring after such a procedure. 1 Factors that predispose patients to infection upon prosthetic valves, especially in the early posternplacement period, are trauma, foreign hody, focus of infection in sutures, and white blood cell dysfunction after extracorporeal circulation. 1 Patients with bacterial endocarditis in the region of a prosthetic valve are necessarily treated with large quantities of antibiotics. ~Iassive antibacterial therapy may predispose patients to superinfection with fungi. 2 This report describes a patient with fungal septicemia and possible fungal endocarditis due to Saccharomyces. Fungemia occurred following antibiotic therapy for suspected bacterial endocarditis upon a prosthetic valve. Saccharomyces is a yeast used industrially to ferment carhohydrates in the production of beer, wine and bread. It grows as a saprophytic organism on the skin and in the gastrointestinal tract of human beings.:l Careful review of the literature failed to show any previous reports of infection due to this organism. This report emphasizes that organisms that are usually nonpathogenic may cause infection, especially in patients with prosthetic heart valves. It suggests that some fungcmias, presumably those due to organisms of low virulence, may be cured with doses of amphotericin B that are ordinarily subcurative. It indicates that some patients with prosthetic valves who have had a fungus cultured from the blood may be successfully treated by medical therapy and therefore may be spared replacement of the prosthesis. CASE REPORT

Th.. patient wa' a 54-year-old whit.. woman hospitalized at Crei!thton " ..moriaI SI. Jos..ph·s Hospital in ~[arch, 1967, for ins<>rtion of a mitral prosth..tie valv... She had suffered two typical episodes of acute rheumatic fever at 11 and 15 years of age. Shortnl'SS of hreath with e,..rtion had ""'-'n pr<>sent since al:e 39. The patient had """n confined in different hospitals on five ()(.'caliinns because of pulmonary congt'Stion and ri!tht ventricular failure. In spite of therapy with digitalis

and diuretics, symptoms had become progressively worse in tht> six months prior to admission. Physical examination, ('onfirnwd hy cardiac cath('terizatioo and n'ntriculography, showed a tiJ,tht immohile mitral valve and moderate mitral reJ,tuTJ,titati()ll.

A Starr-Edwards prosthetic mitral valve wa' inserted on \Iardl 23, 1967. Prophylaetk antihiotic therapy with lincomycin 2 !tm/day wa' !tiven for ten days following surgery. (The patient was aller!tic to penicillin). On the 12th postoperative day, the patient's oral temperature was 102' F and her white e...J1 eount was 21,OOO/mm 3 . Thl'S" findings were a.....licx·iated with roentgenographic evidence of pneumonitis.

For this rt°asnn, lincomycin was continued another week.

Between th.. 12th and 20th days after operation the patient

suffered epi,odes of confusion and a single episode of transient blindness. On two ncca'ions diphtheroids were cultured from blood specimens. Samples of blood from the cardiac hypa" pump also had shown diphtheroids. Splenomegaly became apparent three weeks after surgery. Conjunctival

petechiae were noted, and oral temperah"es remained at 102' F. Because of the strong suspicion of prosthetic valve endocarditis due to diphtheroids, treatment with chloramphenicol 1 gm/day and cephalothin 12 !tm/day was given for three weeks. Chlortetracycline 1 gm/day and lincomycin 3 gm/day were given in combination for another three weeks followed by kanamyC'in 700 mg/day for three w""k., because of continued fever and leukocytosis. In summary, the patient received large doses of antibiotics for 12 week.s following sur,:tery.

During the 8th and 12th postoperative weeks, y..a,t was

culhtred from one blocx:l specimen and two urine specimens.

The genus of the yeast was not determined. A periprosthetic insufficiency murmur was heard for the 6rst time during the ninth postoperative week. A fever of 104' F dev.-!oped during the 15th postoperative week. Five hlood specimens were taken at different times durinp; the da)' that the fes·er de""loped, and from each a Saccharomycl'S wa' culhm-d. No intravenous catheters were in place at the time that the blood sampll'S were obtained, although one had """n removed 24 hours previously. Because yea,t had """n t'ulh"ed from the hlood and from the urine on several occasion.' over an eightweek period, and because a periprosthelic re!tur!titant murmur and hi!th fever developed, it seemed that treatm..nt with amphotericin B was indicated. A total dos.. of 1.4 !tm of amphotericin B wa...,. given over a pt"ri(xl of ten weeks.

Therapy with amphotericin B wa' terminated because of prolonged oliguria associated with a rising hl,x>d urea nitro«en level that reached a peak of 61 m!t/IOO ml. Following the initiation of amphotericin B therapy, no fungi were eulhued from over 40 samples of hlood. Blood specimens

continued to show no organisms one year after amphotericin

B was discontinued. The periprosthetic re!turgitant murmur persisted, hut the left ventricle did not appear to enlarge durin!t that year. DISCUSSIOS

Fungemias from other saprophytic fungi have been reported.~-t1 Underlying serious disease, antibiotic or corticoid therapy, and indwelling vascular catheters seem to have been related to the fungemia in these cases. ~ - tl \\bether fungemia in this patient indicated a fungal infection in the region of the prosthetic valve cannot be stated with certainty. A periprosthetic regurgitant murmur appeared shortly after yeast was cultured from the blood. Yeast compatible with Saccharomyces previously had been cultured from the blood and urine intermittently over a period of eight weeks. Fungal endocarditis, on some occasions associated with bacterial endocarditis, in the region of a prosthetic valve has been shown at autopsy in other patients. 1. 7-11 Positive identification of the yeast as Saccharomyces was based on the morphology of stained specimens, characteristic growth patterns on differential media, and biochemical studies includ-

CHEST, VOL. 58, NO.2, AUGUST 1970

175

EARLY OPERATION FOR PAPILLARY MUSCLE RUPTURE

ing carbon assimilation. nitrogen assimilation, carbohydrate fermentation, starch hydrolysis, and gelatin hydrolysis. I 0- 12 Regarding the morphologic characteristics which were relied upon for identification, it is important to note that Saccharomyces are ascomycetous yeasts. II Budding ceases at a certain stage of growth and the vegetative cells become transformed into ovoid asci, each containing four ascospores. Pairs of germinating ascospores, or the first vegetative cells produced from them, fuse to form diploid vegetative celIs. 12 Diploidy is maintained throughout the entire subsequent period of vegetative development, and meiosis occurs directly prior to formation of ascospores. 11 Other ascomycetous yeasts do not reproduce in exactly this same manner and thus have different characteristic morphologic forms. I " In this case, the characteristic ovoid asci containing four ascospores were demonstrated in all isolates by a modified acid-fast staining technique. ;'\0 attempt was made to identify the organism according to species because there is a difference of opinion concerning criteria for species differentiation among various authors. I :<-1 r, It is unfortunate that identification was not made of the yeasts isolated from the blood and urine during the eighth and twelfth weeks after surgery. These organisms were shown to be true yeasts by morphologic characteristics and carbohydrate fermentation studies. I " The fact that they were true yeasts, and not the more common yeast-like pathogens such as Candida, suggests that they were the same type of fungus, Saccharomyces, that was recovered from subsequent blood samples. Those of us who did not see the patient until three months after surgery (P.S., A.F., and K.H.) wish to thank the physicians responsible for her care prior to that time. ACKNOWLEDG~IE:\"T:

REFERE:-;CES

2 3 4

5 6 7 8

Stein, PO, Harken, DE, Dexter, L: The nature and prevention of prosthetic valve endocarditis, Amer Heart J 71 :391,1966 Andriole, \iT, Kravetz, H~I, Roberts, WC, et al: Candida endocarditis, Amer J ~led, 32:251, 1962 Bessey, EA: ~Iorphology and Taxomony of Fungi, :'>lew York, Hafner Puhlishing Co., 1961 Louria, DB, Blevins, A, AnnstTong, 0, et al: Fungemia caused by "non-pathogenic" yeasts, Arch Intern \Ied 119:247, 1967 Ellis, CA, Spivack, ~IL: The sil':llificance of candidemia. Ann Intern \Ied 67 :.511, 1966 Shelburne. PF, Carey, RJ: Rhodotomla f"ngemia complicating staphylococcal endocarditis, JA\IA, 180: 118, 1962 Climie, ARW, Rachmaninoff, :--;: Fungal (Candida) endocarditis following open-heart surgery, J Thorac Cardiovasc Surg .50:431, 1965 Leffert, RL, Hackett, RL: Aspergillus aortitis following replacement of aortic valve. J Thorac Cardio\'asc Surg 53:866,1967

CHEST, VOL. 58, NO.2, AUGUST 1970

9 :\"ewman, \VH, Cordell, AR: Aspergillus endocarditis after open-heart surgery, J Thome Cardiovasc Surg 48:6,52, 1964 10 Aiello, L, Georg, LK, Kaplan, W, et al: Lah \Ianual for ~le.Jical ~Iycology, Puh. No. 994. 1966, Public Health Sen'ice, U.S. Department Healtb, Education and \\'elfare, 1966 11 Stanier, RY, Doudorff, \1, Adelherg, EA: The ~Iicrobial World (2nd cd), Prentice Hall, Englewood Cliffs, 196.3 12 Henrici, A, Ordahl, E: The Biology of Baeleria (3rd cd) Boston, D. C. Heath and Co., 1948 \.3 Salle, A.J.: Fundamental Principles of Bacteriology (5th ed), '\ew York, ~lcGraw-HiII, 1961 14 Lodder, J, Kreger-Van Rig, i\JY: The Yeasts, Amsterdam, "orth-Holland Puhlishing Co., 1952 \.5 Skinner, CE, Emmons, C\V, Tsuchiya, H~I: Henric;'s ~lolds, Yeasts and Actinomycetes (2nd cd), '\ew York, John Wiley and Sons, 1948

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Reprint requests: Dr. Stein, University of Oklahnma School BOO Xortbeaxt Thirteenth StTeet, Oklahoma City, of ~Iedicine, Oklahoma 73104.

Successful Early Operation for Papillary Muscle Rupture* Robert F. DeBusk, .\I.D., Robert E. Kleiger, M.D., Carl L. Elmo/her, .\I.D., Pat O. Daily, M.D., and Donald C. Harri.son, .\I.D.

This is the earliest reported intervention in a syndrome which clinicians are seeing with increasing frequency. The diagnosis of a ruptured papillary muscle which is one of the disastrous complications of acute myocardial infarction requires early angiocardiography and catheterization when the condition is suspected. When adequate ventricular function is preserved, successful valve replacement is possible. hrnODlTTlO:-;

papillary muscle rupture has been considered a medical curiosity until recently. Recognition of this potentially treatable complication of myocardial infarction has been stimulated by the increasing frequency with which successful surgical treatment has been reported. This is the 22nd reported case of papillary muscle rupture approached surgically, and is to our knowledge the earliest surgical attempt following infarction. CASE REPORT

A .53-year-old electrician wa.' admitted to Stanford Vni\'ersit)' Hospital on Decemb"r II, 1968 hecause of chest pain. In 19.54, he had suffered an uncomplicated acute inferior wall mroeardial infarction. Five days prioT to admission, he had noted transient mild, right upper chest pain radiating to both sides of the neck; electTocardiogram and chest x-ra~ °From the Cardiology Division, Stanford University Sdl<~lJ of ~Iedicine, Palo Alto, California. This work was supported in part by '\IH Grants '\os. HE,5709 and HE-o.5866.