Aspergillus prosthetic valve endocarditis presenting as acut
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Aspergillus endocarditis is the 2nd most common form of fungal endocarditis after that caused by Candida species.

The outcomes for patients with prosthetic valve endocarditis due to Aspergillus species have been extremely poor.

Medical management alone is almost uniformly fatal. It is therefore of utmost importance for a clinician to take the invaluable assistance from radiologist, surgical pathologist and microbiologist to arrive at the final diagnosis.

52 years male with severe calcified mitral stenosis (rheumatic etiology) recent history of early onset culture negative native valve endocarditis and diagnosed on the basis of symptoms and vegetation on echocardiogram and was treated with ceftriaxone and gentamicin for 6 weeks and has undergone mitral valve replacement with bioprosthetic valve presented to hospital with fever, chills and rigor after almost 2 months of operation.

His TLC count was 11,600, CRP was raised and creatinine was 2.1. His TTE showed a large echogenic valvular mass measuring 2.3 × 1.3 cm in prosthetic valve leaflet. During hospital stay patient developed severe pain in buttocks and right lower limb. On clinical examination pulses were feeble in right femoral artery. Immediately colour Doppler of right lower limb was done which suggested dampened flow in femoral, popliteal, tibial and dorsalis pedis artery and suggested proximal obstruction. CT angio of abdominal aorta and peripheral limb revealed saddle shaped thrombus in aortic bifurcation and right femoral artery. Femoral Embolectomy was performed. Embolectomy specimen showed braching septate hyphae suggestive of Aspergillus species. Mean while patient developed severe breathlessness and new onset pan systolic murmur on auscultation and developed pulmonary oedema hypotension and Echocardiogram showed severe mitral regurgitation with destruction of prosthetic valve, emergency redo mitral valve replacement was performed. The prosthetic valve was completely destroyed and had black coloured vegetation over it.

Complete explantation of valve along with vegetation was done and was replaced with 27 NO. Perimount valve. In post operative period patient was treated under keen observation of intensivist and nephrologist with intra venous liposomal AmphotericinB and Voriconazole for 2 weeks then on oral voriconazole.