Title : Quadruple‑valve endocarditis due to candida parapsilosis: A previously unreported presentation
Abstract:
Introduction: Four-valve endocarditis is exceedingly rare, typically bacterial in origin, and associated with high morbidity and mortality. To our knowledge, we report the first case of quadruple-valve endocarditis caused by Candida parapsilosis.
Case Presentation: A 38-year-old female with a history of intravenous drug use (IVDU), prior Staphylococcus aureus tricuspid valve endocarditis, and end-stage renal disease on hemodialysis (HD) via right jugular permcath presented with fluid overload after missing HD for months. On arrival, she was afebrile, tachycardic, with renal failure. Due to non-functioning HD catheter, a femoral line was placed for emergent HD, blood cultures (Bcxs) and permcath culture were obtained, and vancomycin and ceftriaxone were initiated. On hospital day two, Bcxs grew Streptococcus mitis and antibiotics were narrowed. The permcath was removed on hospital day two with purulence noted. Bcxs were repeated. Transthoracic echocardiogram (TTE) demonstrated vegetations on all four valves. On hospital day five, Bcxs from day two grew Candida parapsilosis, prompting initiation of fluconazole. Permcath culture remained negative. Transesophageal echocardiogram (TEE) confirmed involvement of the aortic, mitral and tricuspid valve, with severe dysfunction; pulmonic involvement was not visualized. Her hospital course was complicated by septic emboli to the lungs, kidney, left thigh, brain and retina.
Persistent candidemia, despite multiple line holidays, prompted addition of micafungin on day 13. On day 17, she underwent aortic valve replacement, repair of aortic root abscesses, and mitral and tricuspid valve repair. Intraoperative aortic valve tissue culture confirmed Candida parapsilosis. Bcxs cleared postoperatively. Micafungin was discontinued on day 23. She completed a six-week course of ceftriaxone and high dose fluconazole from day of surgery and was discharged on day 69 on fluconazole with plans for suppression.
Conclusion: This case describes previously unreported quadruple-valve endocarditis due to Candida parapsilosis. It highlights the aggressive nature of fungal endocarditis, particularly in patients with indwelling vascular access and IVDU. Diagnosis may require multimodal imaging, as valvular involvement can evolve or embolize – in our patient pulmonic valve involvement was suggested on TTE but not confirmed on TEE, with embolization remaining a possible explanation. Management necessitates prolonged antifungal therapy and complex surgical intervention. Early recognition and multidisciplinary care are critical to improving outcomes.
