Fungal endocarditis after hybrid periventricular closure of muscular ventricular septal defect by Amplatzer occluder in a child.

A 2-year-old boy was admitted for a 16-day history of intermittent fever (up to 40.5°C) with no other symptom. He had been followed since birth for a large midmuscular ventricular septal defect with a left-to-right shunt and signs of congestive heart failure. At 2 months of age, the patient had a pulmonary artery banding, and at 16 months of age he underwent hybrid periventricular closure of a muscular ven-tricular septal defect by Amplatzer occluder and removal of the pulmonary band. A 12-mm Amplatzer muscular ventricular septal defect (VSD) occluder was implanted through a direct puncture of the right ventricular free wall. Postoperative echocardiogra-phy initially showed a 7-mm residual muscular VSD at the inferior border of the device with a moderate left-to-right shunt that progressively decreased to a 3-to 4-mm residual VSD over the next few months. During postoperative follow-up, the patient's condition improved with decreasing heart failure signs. Treatment with diuretics and angiotensin-converting enzyme inhibitor, and aspirin as well, was continued. Over the next 8 months he received several courses of antibiotics for various infections. On admission, the patient was subfebrile (37.7°C). His heart rate was 144 bpm, blood pressure was 121/75 mm Hg. Chest examination revealed a holosystolic murmur at the midleft sternal border with irradiation to the apex. There were mild subcostal retractions, diminished vesicular sound, and expiratory crackles on the right basal lung field. Laboratory examination showed elevated inflammatory signs: leukocytosis at 24.6 g/L, elevated C-reactive protein at 283 mg/L, and elevated sedimentation at rate 71 mm/h. Chest x-ray showed diffuse bilateral infiltrates and right lower lobe condensation. Endocarditis was suspected by transthoracic echocardiog-raphy and confirmed by transesophageal echocardiography and blood cultures. Transesophageal echocardiography showed a large irregular echogenic mass measuring 22×12 mm, attached to the right disc of the VSD occluder, that did not compromise the tricuspid valve nor cause tricuspid regurgitation (Movie I in the online-only Data Supplement). A 4×3 mm residual muscular VSD was seen at the lower border of the VSD occluder device. Successive blood cultures were positive for multisensitive Candida albicans. Therefore, the patient was started on intravenous antifungal treatment with caspofungin. His physical condition improved, but the fever persisted. Laboratory values for inflammation decreased. A repeated transesophageal echocardiogram 6 days later showed no changes and no reduction in the size of the large vegetation. Subsequently, because of the fungal nature of the endo-carditis and the infection of prosthetic material, the patient …