Fever and Peripheral Emboli in an Immunocompetent Host. A Case of Aspergillus Endocarditis

Despite diagnostic and therapeutic advances in medical, surgical, and critical care, the mortality rate for Aspergillus endocarditis remains dismal (approaching 100%). We report a case of a 49 year old immunocompetent woman with recent aortic valve prosthesis who presents with fever, chills, sweats, left facial droop, left arm weakness, petechial rash and cyanotic toes. Initial trans-esophageal echo was normal but a repeat study revealed a 9 × 5 mm vegetation abutting the aortic pros- thesis. Microbiological correlation could not be documented despite the presence of persistent fever through serial blood cultures, and the diagnosis of Aspergillus fumigatus endocarditis was ultimately made on embolectomy specimen when she developed an ischemic right leg. Aggressive medical treatment was initiated with intravenous voraconazole, liposomal amphotericin-B and heparin. The timing of surgical intervention was contemplated, but was precluded by multiple comorbidities. She succumbed to her illness after developing cerebral herniation following intraparenchymal hemorrhage.The effectiveness of combined medical intervention and surgical valve replacement for Aspergillus endocarditis is therefore contingent on high diagnostic suspicion and early echocardiographic detection in a high risk individual with features of culture-negative endocarditis.