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Candida albicans endocarditis in a human immunodeficiency virus infected patient successfully treated with caspofungin and vegetectomy: a case report

History: A 22-year-old male i.v. drug user acquired acute HIV infection in September 2003. At that time he was admitted to a hospital outside Croatia and treated for mixed bacterial (Streptococcus sanguis) and fungal (Candida albicans) sepsis with tricuspid valve endocarditis. His hospitalization was complicated by pulmonary embolism, femoral thrombosis and bilateral pneumonia that required bilateral thoracic drainage. His Candida albicans infection was treated with liposomal amphotericin B for 3 weeks followed by oral fluconazole. He was discharged in December 2003 in a stable condition and given fluconazole (400 mg/day) and methadone maintenance therapy. Case presentation: The patient was admitted to our hospital in March 2004 because two blood cultures taken in the outpatient setting grew Candida albicans despite continuous fluconazole therapy. Echocardiography was performed and a vegetation 2 cm in diameter was found on the tricuspid valve, and there was also a thrombotic mass 0.5 cm in diameter in the right ventricle. A 2-week course of liposomal amphotericin B with intravenous fluconazole (400 mg/day) was given, followed by oral fluconazole (400 mg/day). The patient became afebrile, however, a blood culture taken in May 2004 grew Candida albicans again. On June 2nd surgery was performed with excision of the vegetations on the tricuspid valve and in the right ventricle. One the day prior to surgery treatment with intravenous caspofungin (70 mg on day 1 followed by 50 mg/day) was started. Candida albicans grew from the cultured vegetations, it was susceptible to fluconazole and amphotericin B. Intravenous caspofungin was given for 4 weeks followed by oral fluconazole (400 mg/day). In the following 4 months no recrudescence of endocarditis was observed. Antiretroviral treatment was started in April 2004 with a combination of stavudine, lamivudine and lopinavir/ritonavir. It was given throughout the course of illness and was well tolerated. Conclusion: Initial caspofungin treatment followed by fluconazole maintenance therapy, in addition to vegetectomy, was successful in the treatment of Candida albicans right-sided endocarditis in our HIV infected patient.

Candida albicans; Endocarditis; HIV

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