Clinical Infection in Practice (Jul 2023)
Trichosporon inkin and Cutibacterium acnes bioprosthetic aortic valve endocarditis and prosthetic aortic root abscess with multi-focal emboli
Abstract
Background: This report presents the first case of a patient with dual pathogen-associated bioprosthetic aortic valve endocarditis, prosthetic aortic root abscess and multifocal septic emboli, caused by both Trichosporon inkin and Cutibacterium acnes. Case Report: A 67-year-old male with a prosthetic aortic root replacement, bioprosthetic aortic valve and pacemaker presented with pyrexia, right arm numbness and confusion. Multiple left-sided embolic infarcts were found on brain imaging, eye examination was consistent with right-sided fungal endophthalmitis, and an aortic valve vegetation and aortic root abscess were visualised on trans-oesophageal echo. Pre-operative blood cultures were negative. Revision surgery tissue samples grew Trichosporon inkin and Cutibacterium acnes. Post-operatively, he was treated with 42 days of meropenem and 150 days of antifungals (ambisome plus flucytosine plus intravitreal voriconazole, followed by oral voriconazole), after which he was switched to long term oral suppressive therapy with doxycycline and fluconazole. Twelve months post operatively, he is well and there is no evidence of recurrence. Discussion: Trichosporon prosthetic valve endocarditis has a 62% one-year mortality rate. This case presented additional complexity: dual infection with Cutibacterium acnes, multi-focal embolic disease, difficulty in obtaining a pre-operative microbiological diagnosis, and difficulty with antifungal treatment (toxicity risk, drug interactions, minimal evidence-based for treatment). Managing complex cardiothoracic infections involving prosthetic material, such as that described, requires a multi-disciplinary approach, involving cardiothoracic surgeons, infection specialists and pharmacists, and other allied health professionals if necessary, to optimise patient care and reduce morbidity and mortality.
