P238 Chemotherapy venous access port endocarditis in a patient with breast cancer

Abstract

Background/Introduction: Right sided infective endocarditis (IE) accounts for less than 10% of all IE cases. Predisposing factors include portal of entry, implanted foreign material and unrepaired congenital heart disease with conduit. Fungal endocarditis (FE) constitutes the most severe form of IE and is etiologically connected predominantly to Candida and Aspergillus species. Among these two agents, Candida species is a common nosocomial infection with increasing prevalence and mortality rates up to 40% in cases of systemic candidiasis. Individuals with different forms of solid or hematological malignancies, under chemotherapy regimens or bone marrow transplantation comprise a particularly susceptible patient population. Case presentation: A 58 year old woman with personal history of triple negative breast adenocarcinoma stage IV under palliative chemotherapy, administered for metastatic mass riknosis in the gastrointestinal tract, was admitted to the Emergency Department of our Hospital due to persistent fever, malaise and dyspnea on effort. Chemotherapy was infused via an implantable venous access port (intraport catheter). Methods/Results: Her heart auscultation revealed a holosystolic ejection type murmur of 3/6 located in the third intercostal space of changing quality. Candida tropicalis was isolated in three separate blood cultures. Transthoracic echocardiography demonstrated a good overall left ventricular systolic function. The right cavities were moderately dilated with moderate tricuspid regurgitation and a pulmonary pressure estimated at 45 mmHg. A large vegetation (approximately 2 cm maximal diameter) at the atrial surface of the posterior and diaphragmatic leaflets of the tricuspid valve with parts of the vegetation periodically apparent in the right ventricle was observed. Transesophageal echocardiography confirmed the findings of the transthoracic study and elucidated in the bicaval view the connection of the vegetation in the tricuspid valve with the edge of the intraport catheter. Moreover computed tomography scan revealed multiple pulmonary emboli in the segmental branches of the bronchial tree and a circumscribed peripheral pulmonary infarct of the left inferior lobe. A multidisciplinary team concluded that the best treatment strategy would require aggressive intravenous combined antifungal therapy until eradication followed by removal of the implantable venous access port, which was uncomplicated. Conclusions: The majority of fungal endocarditis episodes represented healthcare-associated infections in vulnerable subsets of patients. Treatment of Candida endocarditis can prove challenging because of the formation of biofilms on prosthetic devices often requiring combination therapy. Septic pulmonary embolism with multiple loci is a frequent complication in right sided infective endocarditis. Removal of the prosthetic device if feasible in addition to antifungal treatment is linked to a more favorable prognosis.(Figure Presented).