Emerging trends in fungal endocarditis: clinical complexity, diagnostic challenges, and therapeutic implications – a case series and literature review

Abstract

Background: Fungal infective endocarditis (IE) is a rare, yet increasingly recognised condition associated with substantial mortality rates. Candida and Histoplasma are among the notable causative agents, presenting diverse clinical manifestations and complexities in diagnosis and management. Objectives: This study was undertaken to examine the clinical profiles, diagnostic challenges, treatment modalities, and outcomes of four compelling cases involving Candida and Histoplasma endocarditis. Methods & Design: This was a descriptive case series study conducted from July 2021 to July 2023. All patients with definite/possible endocarditis diagnosed based on modified Duke’s criteria were reviewed in this study. Data on demographics, risk factors, clinical signs and symptoms, echocardiography findings, microbiological aetiology, complications, treatment, and outcomes were collected. Results: Among 212 suspected IE cases reviewed, 54 met the modified Duke’s criteria for possible or definite IE, with four instances identified as fungal endocarditis. Candida species accounted for three cases, while an uncommon instance of Histoplasma Endocarditis (HE) was also observed. Clinical presentations varied, with fever and dyspnoea being prominent symptoms. Risk factors included chronic kidney disease, prior surgeries, prosthetic valves, and immunocompromised states. Diagnosis posed challenges due to the resemblance to bacterial IE, low blood culture yields, and delayed suspicion. Various diagnostic approaches, including blood cultures, serological markers, and imaging, were employed. Therapeutic strategies involved antifungal agents and surgical intervention, where feasible. However, despite prompt treatment initiation, many patients faced rapid clinical deterioration, emphasising the severity and aggressive nature of fungal endocarditis. Mortality rates remained notably high across the cohort. Conclusion: This study highlights the criticality of early suspicion, prompt diagnosis, and a multidisciplinary approach to managing fungal endocarditis. While recognising the limitations in current diagnostic tools and therapeutic options, the study underscores the urgent need for enhanced diagnostic modalities and novel treatment strategies to improve outcomes in these challenging cases.