Copyright © 2005, The European Society of Cardiology
Voluminous mycetoma in a newborn with down syndrome: Role of echocardiography
aUniversity of Foggia, Department of Cardiology, viale Luigi Pinto, 1. 71100 Foggia, Italy
bHospital OO.RR Foggia, Neonatal Intensive Care Unit, Foggia, Italy
Received 7 June 2005; received in revised form 4 July 2005; accepted after revision 27 July 2005.
* Corresponding author. Tel.: +881733652; fax: +881745424. opsfco{at}tin.it
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Abstract |
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We report a case of a baby with Down Syndrome and history of a corrective surgery for a duodenum stenosis, which was subjected to a parenteral nutrition with central venous catheter. A two-dimensional color Doppler echocardiographic examination revealed a voluminous oval-shaped mobile inhomogeneous mass adhering to the tricuspid valve. The intraoperative pathology showed that it was a large fungal vegetation. The probable source of Candida Albicans was an infected intravenous catheter. We wish to remark the role of echocardiography in the diagnosis and choice of timing of surgery.
Keywords: Endocarditis; Vegetation; Echocardiography; Central venous catheter
A female premature newborn with Down Syndrome and history of a corrective surgery for a duodenum stenosis was subjected to a parenteral nutrition with central venous catheter (sylastic catheter). She was referred to our echocardiographic laboratory to rule out the hypothesis of a congenital cardiopathy. At the time of the first examination a persistent patency of oval-shaped foramen was found. After one month, for hemodynamic derangement, a new two-dimensional color Doppler echocardiographic examination was performed (SONOS 5500, Hewlett Packard technology); it revealed both a voluminous mobile mass adherent to the tricuspid valve and a dense layer of echoes near to the basal segment of the free wall of the right ventricle. A small pericardial effusion and a tricuspid annulus thickening were detected by echocardiography, too (Fig. 1). Endocarditis diagnosis was suspected from the clinical picture, positive blood cultures and, above all, echocardiographic features mass. The intracardiac mass was inhomogeneous, oval-shaped, with quite regular edge and central area echolucent appearance. It did not allow a normal filling of the right ventricle. A surgical removal was urgently performed for a severe hemodynamic derangement and right-sided heart failure. The mass was excised, but a moderate tricuspid regurgitation was resulted (Fig. 2); the intraoperative pathology showed that it was a large fungal vegetation. After the mass surgical removal, dramatically hemodynamic conditions improved, persisting in the 6 months and 1 year follow up.
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Echocardiography is currently considered as one of the main tools in the diagnosis and treatment of infective endocarditis.1,2 Using echocardiography it is possible to localize the vegetation exactly and estimate the extent of valvular involvement. Vegetation features were defined as irregularly shaped echogenic masses adherent to valves or endothelial surface. Variables used to differentiate vegetations from noninfection masses (thrombus formation, tumoral mass) included oscillating motion (high frequency movement independent of the associated valvular motion), mobility (exceeding and independent of the associated valve structure) and shaggy or irregular surface. In this report the size of this vegetation (the dimensions were 15x17mm) and its mobility give a negative prognostic value, in fact large and extensive ones that are more mobile and soft are more closely associated with complications and embolic event.3 We have immediately supposed a mycotic vegetation because these vegetations are larger than those found in bacterial endocarditis4 and because often these adhere to valve leaflet with a right ventricle inflow tract obstruction. The intraoperative pathology showed that it was a large fungal vegetation and the blood cultures were positive for Candida Albicans. The probable source of Candida was an infected intravenous catheter. In fact a central venous line had been installed for parenteral nutrition, because a surgical correction (duodeno-duodeno-stomy) was performed at the 10th day of life.
A surgical removal was urgently performed for a severe hemodynamic derangement, for embolic event risk, for a right ventricle inflow tract obstruction and for possible right ventricular free wall rupture after infective process extension at the right ventricle free wall basal segment. In this way early intervention, before the onset of severe heart failure, had improved the prognosis and intraoperative risk.
The echocardiographic examination of post-surgery showed absence of mass, mild pericardial effusion, tricuspid annulus thickening and moderate tricuspid regurgitation (pressure in right ventricle: 35mmHg) with mild dilatation of the right ventricular inflow tract. In conclusion, newborn subjected to a parenteral nutrition with central venous catheter must have undergone several echocardiographic examinations in order to rule out both thrombotic formation and vegetations and, above all, the presence of very large vegetations should immediately make the echocardiographer suspect fungal rather bacterial infection.
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- Durack D.T., Lukes A.S., Bright D.K. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med (1994) 96:200–209.[CrossRef][Web of Science][Medline]
- Li J.S., Sexton D.J., Mick N., Nettles R., Fowler V.G. Jr., Ryan T., et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis (2000) 30:633–638.[CrossRef][Web of Science][Medline]
- Di Salvo G., Habib G., Pergola V., Avierinos J.F., Philip E., Casalta J.P. Echocardiography predicts embolic event in infective endocarditis. J Am Coll Cardiol (2001) 37:1069–1076.
[Abstract/Free Full Text] - Ellis M.E., Al-Abdely H., Sandrige A., Greer W., Ventura W. Fungal endocarditis: evidence in the word literature, 1965–1995. Clin Infect Dis (2001) 32:50–62.[CrossRef][Web of Science][Medline]
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