Vol.2, No.5, 315-317 (2013) Case Reports in Clinical Medicine
http://dx.doi.org/10.4236/crcm.2013.25084
Premature newborn with intracardiac fungus balls
and endocarditis which is curable only with
anti-fungal therapy: Case presentation
Mecnun Cetin*, Serkan Ozen, Munevver Yildirimer, Murat Deveci, Senol Coskun,
Metehan Kizilkaya
Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Celal Bayar University, Manisa, Turkey;
*Corresponding Author: [e-mail]
Received 22 November 2012; revised 26 December 2012; accepted 3 January 2013
Copyright © 2013 Mecnun Cetin et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Invasive fungal infections often caused by Can-
dida species are infections which have high
morbidity and mort ality rates in newborn infant s.
5% of the cases have also concomitant endo-
carditis and this causes mortality rates ov er 60% .
Thus it has vital importance to diagnose and
treat these patients with endocarditis in early
stages. Most preferred treatment option is a sur-
gical incision in addition to systemic anti-fungal
therapy. Here we presented an extremely low
birth weight, premature newborn with endocar-
ditis caused by Candida tropicalis and cured
solely by systemic anti-fungal treatment without
the need for surgical intervention.
Keywords: Invasive Fungal Infection; Endocarditis;
Candida tropicalis
1. INTRODUCTION
Frequency of invasive fungal infection in newborns is
increasing due to the reasons such as increasing number
of low/extremely low birth weight newborns that are
hospitalized in newborn intensive care units, increased
invasive interventions, need for parenteral nutrition, use
of broad-spectrum antibiotics and need for long term
mechanical ventilation [1]. The most common infectious
agent is C. albicans. These fungal infections develop
severe symptoms in extremely low birth weight new-
borns and have mortality rates of 30% - 60% [2]. Endo-
carditis develops in 5% of invasive Candida infections
and these cases have over 60% mortality rate. In this
article a case of extremely low birth weight newborn
with endocarditis caused by Candida tropicalis and cured
by only systemic anti-fungal therapy due to high risk of
mortality with surgical intervention, anticoagulant and
thrombolytic treatment is presented.
2. CASE
Female baby, who was born 980 gr. from 24-year-old
mother’s first pregnancy, with C-section at 28 weeks
because of umbilical cord prolapse, had APGAR scores
of 3 and 7 respectively at 1st and 5th minutes. After five
hours, with onset of respiratory distress, grunting, apnea
and presence of acidosis and hypoxia in her arterial
blood gas, patient was intubated and connected to me-
chanical ventilator. Umbilical catheter was inserted and
TPN solution and sefotaxim (100 mg/kg/day, two doses)
plus amikacin (18 mg/kg/dose, in every 35 hours) was
initiated. With the detection of reticulonodular pattern in
PA chest radiography patient was diagnosed as respira-
tory distress syndrome and administered surfactant.
Complete blood count and biochemical values of the
patient were normal. On third day, stage III hemorrhage
in left hemisphere was detected on transfontanel ultra-
sonography. On the fourth day, Patent Ductus Arteriosus
(PDA) was found by transthoracic echocardiogram (TTE)
that was performed upon detection of 2/6 grade systolic
murmurs during cardiovascular system examination. Pa-
tient received three doses of intravenous ibuprofen (first
dose of 10 mg/kg and subsequent two doses of 5 mg/kg)
with 24 hour intervals. In control echocardiogram per-
formed one week later it was observed that PDA was
closed. However at the interconnection of vena cava in-
ferior and left atrium a hyperechoic mass (fungus ball) of
11.3 mm × 5 mm (Figure 1) was spotted. Same day as
yeast cell proliferation in previously collected blood cul-
ture sample was detected, abdominal catheter was re-
moved and systemic liposomal amphotericin B therapy

M. Cetin et al. / Case Reports in Clinical Medicine 2 (201 3) 315-317
316
Figure 1. Appearance of the fungus ball at interconnection of
vena cava inferior and right atrium (IVC: Inferior vena cava;
HV: Hepatic vein; RA: Right atrium).
(6 mg/kg/day, one daily dose) was initiated. Later it was
realized that proliferated agent in the blood culture was
amphotericin B sensitive Candida tropicalis and same C.
tropicalis proliferation was observed in both second
blood culture and abdominal catheter culture. There was
no proliferation in urine culture. Lumber puncture and
eye examination was normal. Patient was intubated and
extubated sporadically 3 times with recurrent severe ap-
nea exacerbations during the follow-ups. Surgical exci-
sion was planned for patient’s fungus ball in the vena
cava inferior but patient’s extremely low birth weight,
unstable clin ical condition and high cardio-pulmoner by-
pass risk postponed the surgery and only liposomal am-
photericin B therapy was continued. We couldn’t use
anticoagulant and thrombolytic treatment due to presence
of intracranial hemorrhage. In periodically obtained echo-
cardiograms of patient during follow-ups, shrinkage of
fungal mass was observed. At the 50th day of the anti-
fungal treatment complete disappearance of the mass was
observed (Figure 2) and treatment continued in follow-
ing next 10 days. Patient was administered 60 days of
anti-fungal therapy at total. There were no significant
side effects related to anti-fungal therapy. After clinical
stabilization was achiev ed during follow-ups, pa tient was
discharged from hospital as 2100 gr.
3. DISCUSSION
Candida species can cause organ specific invasive in-
fections aside from non-lethal local mucocutaneous in-
fections. Most common infectious agents in invasive
fungal infections are Candida species [3]. Recently in-
creased number of nosocomial Candida infections among
populations are reported all around the world. In 1960-
70’s most of nosocomial candidasis cases were caused by
Figure 2. Disappearance of fungus ball (IVC: Inferior vena
cava; HV: Hepatic vein; RA: Right atrium).
C. albicans however recently a significant increase in
incidence of infections caused by non-albicans Candida
species (C. tropicalis, C. glabrata, C. parapsilosis, C
krusei, C. guiliermondii, C. lipolytica, and C. pelliculosa)
has been observed [4]. In our case C. tropicalis prolifera-
tion was observed in blood culture.
Risk factors for invasive candidiasis in neonatal period
includes low gestational week, early membrane rupture,
use of H-2 receptor blockers in intensive care units, in-
tubation and mechanical ventilation, the presence of cen-
tral venous catheter, use of broad-spectrum antibiotics,
lack of enteral nutrition and utilization of to tal parenteral
nutrition [5,6]. Five of these risk factors were present in
our patien t .
Systemic fungal infection is reported in very low birth
weight infants less than 1500 g, as the third most fre-
quent cause of late-onset sepsis and is associated with
high mortality [7]. Fungal endocarditis is an uncommon
complication of invasive candidial infection, but there is
a reported increase in the incidence of such infection over
the last 15 years [8,9]. Therefore, early recognition of
infection and therap y is imperativ e.
Invasive candidiasis must definitely be considered in
cases with extremely low birth weight premature new-
borns who have risk factors for candidiasis. Successful
treatment of patients with endocarditis requires early re-
cognition and aggressive treatment. The first and most
basic principle of treatment is elimination of the source
that is associated with increased risk for candidiasis and
the second step is initiating appropriate anti-fungal ther-
apy.
Management of fungal endocarditis in premature in-
fants is controversial. Use of prolonged anti-fungal ther-
apy in conjunction with surgical removal of thrombus is

M. Cetin et al. / Case Reports in Clinical Medicine 2 (201 3) 315-317 317
[2] Zaoutis, T.E., Heydon, K., Localio, R., Walsh, T.J. and
Feudtner, C. (2007) Outcomes attributable to neonatal can-
didiasis. Clinical Infectious Diseases, 44, 1187-1193.
doi:10.1086/513196
shown to be an effective approach to the treatment o f th is
complication [10]. Use of prolonged anti-fungal treat-
ment alone is reported in few critically ill infants with
fungal endocarditis [11]. In our case, due to high risk of
mortality for cardiopulmoner bypass, only 60 days lipo-
somal amphotericin B therapy was administered. Due to
intracranial hemorrhage risk n o anticoagu lant and throm-
bolytic therapy was used. We observed that intracardiac
vegetation shrunk on the 20th day of the treatment and
completely disappeared on the 50th day. There are few
cases, similar to our case, in literature which are treated
and cured by only anti-fungal therapy without the use of
anticoagulants and thrombolytics and surgical interven-
tion.
[3] Lamagni, T.L., Evans, B.G., Shigematsu, M., et al. (2001)
Emerging trends in the epidemiology of invasive mycoses
in England and Wales (1990-9). Epidemiology & Infec-
tion, 126, 397-414. doi:10.1017/S0950268801005507
[4] Trick, W. (2002) Secular trend of hospital-acquired can-
didemia among intensive care unit patients in the United
States during 1989-1999. Clinical İnfectious Diseases, 35,
627. doi:10.1086/342300
[5] Manzoni, P. (2006) Risk factors for progression to inva-
sive fungal infection in preterm neonates with fungal
colonization. Pediatrics, 11 8, 2359-2364.
doi:10.1542/peds.2006-1311
Another aspect that we would like to highlight is the
prophylactic anti-fungal therapy in high risk extremely
low birth weight group patients. Although this is a con-
troversial topic, application of fluconazole prophylaxis
for <1000 gr. newborns have grade A1 level of evidence
in Infectious Diseases Society of America’s (IDSA) Prac-
tice Guidelines and 3 mg/kg fluconazole should be ap-
plied parenterally and in two divided doses for at least 14
days starting from the first day of life [12]. Reason for us
not initiating prophylaxis was due to low frequency of
candidiasis cases in our center.
[6] Benjamin, D.K. (2006) Neonatal candidiasis among ex-
tremely low birth weight infants: Risk factors, mortality
rates, and neurodevelopmental outcomes at 18 to 22
months. Pediatrics, 117, 84-92.
doi:10.1542/peds.2004-2292
[7] Stoll, B.J., Hansen, N., Fanaroff, A.A., Wright, L.L.,
Carlo, W.A., Ehrenkranz, R.A., et al. (2002) Late onset
sepsis in very low birth weight neonates: The experience
of NICHD Neonatal Research Network. Pediatrics, 110,
285-291. doi:10.1542/peds.110.2.285
[8] Kossoff, E.H., Buescher, E.S. and Karlowicz, M.G. (1998)
Candidemia in Neonatal Intensive Care Unit: Trend dur-
ing fifteen years and clinical features of 111 cases. Pe-
diatric Infectious Disease Journal, 17, 504-508.
doi:10.1097/00006454-199806000-00014
We suggest that prophylactic anti-fungal therapy is
essential in cases with high risk factors for invasive can-
didiasis during neonatal period. Besides, serial echocar-
diographic evaluation of newborns with invasive candi-
diasis for possible cardiac involvement should definitely
be performed.
[9] Faix, R.G. (1984) Systemic candida infections in infants
in intensive care nurseries, high incidence of central ner-
vous system involvement. Journal of Pediatrics, 105,
616-622. doi:10.1016/S0022-3476(84)80433-3
As a result, solitary long-term systemic anti-fungal
treatment can be a favorable treatment option in newborn
patients with fungal endocarditis, such as the one in our
case, where surgical intervention, anticoagulant or throm-
bolytic therapy due to their high risk.
[10] Ankola, P.A., Perveen, S. and Fish, B. (2006) Fungal en-
docarditis. Journal of Perinatology, 26, 509-510.
doi:10.1038/sj.jp.7211557
[11] Zenker, P.N., Rosenberg, E.M., Van Dyke, R.B., Rabalais,
G.P. and Daum, R.S. (1991) Successful medical treatment
of presumed Candida endocarditis in critically ill infants.
Journal of Pediatrics, 11 9, 472-477.
doi:10.1016/S0022-3476(05)82067-0
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