A rare case of native valve cryptococcal endocarditis in an immunocompetent patient

SESSION TITLE: Cardiovascular Disease: Hearts and Bugs SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/09/2023 09:40 am - 10:25 am INTRODUCTION: Cryptococcus neoformans is known to cause meningitis, and rarely, it has been associated with endocarditis. The cryptococcal infection commonly affects immunocompromised patients. Cryptococcal endocarditis carries a high mortality rate and nearly always occurs in immunocompromised patients with implanted cardiac devices or prosthetic valves (1). We are presenting a rare case of native valve infective endocarditis and meningitis in an immunocompetent patient. CASE PRESENTATION: A 54-year-old male with a medical history of a T11-T12 spine fracture presented due to a fall and altered mental status. On physical examination, the patient was alert and oriented only to his name (ANO x1) and had T10-L1 spinal tenderness with 3/5 motor power in both lower extremities. A CT of the head was unremarkable, but a CT of the spine showed a C3-C6 spinal cord compression fracture. Laboratory examination revealed a white blood cell count of 12,000 cells/mcL (normal range 4,500–11,000 cells/mcL), hemoglobin of 8.8 g/dL, creatinine of 2.46 mg/dL, and calcium of 18.1 mg/dL. The serum and urine electrophoresis findings were consistent with multiple myeloma. Blood culture x4 was positive for Cryptococcus neoformans. The patient was started on amphotericin B and flucytosine. A lumbar puncture was done, and the findings were consistent with meningitis with a cryptococcal cerebrospinal fluid (CSF) antigen titer of 1:5. A transesophageal echocardiogram (TEE) was obtained due to persistent fever despite appropriate antifungal treatment, and it showed 0.8 cm of tricuspid valve vegetation. Cardiothoracic surgery was consulted for surgical management of infective endocarditis, but the patient was deemed a high risk candidate for surgical intervention given his tenuous clinical condition. A decision was made to treat the infective endocarditis medically. The patient received a total of six weeks of amphotericin B and flucytosine, and a repeat TEE showed a resolution of infective endocarditis. The patient was discharged to subacute rehab after a prolonged hospitalization. DISCUSSION: Cryptococcus neoformans can affect any organ of the body, but it most commonly affects the central nervous system and skin. Cryptococcal endocarditis is a rare entity that carries a high mortality and morbidity (1). The risk factors for cryptococcal endocarditis are immunosuppression, intravenous drug use, a prosthetic heart valve, and HIV. The diagnosis is made using Duke's criteria (1). Most case reports have emphasized the use of amphotericin B in the treatment of cryptococcal endocarditis, with or without surgical intervention. Due to the rarity of the data, no randomized clinical trials have been done to compare amphotericin B versus surgical management (2). Our patient was considered high-risk for surgery; therefore, he was successfully treated with intravenous flucytosine and amphotericin B for six weeks. CONCLUSIONS: Cryptococcal endocarditis is a rare clinical condition that is commonly seen in immunocompromised patients and those with prosthetic heart valves/devices. It should be considered a potential differential diagnosis in patients with infective endocarditis, even if they are immunocompetent. With a mortality rate of 44%, timely diagnosis is critical for optimal outcomes. REFERENCE #1: McGuire C, Walter D, Wopperer S. Cryptococcus Neoformans Endocarditis in an Immunocompetentpatient a Case Report. BMC Cardiovasc Disord. 2022;22(1):565. REFERENCE #2: Roy M, Ahmad S, Roy A. Cryptococcus Neoformans Infective Endocarditis of Native Valves in an Immunocompetent Host. IDCases. 2018;12:66-70. DISCLOSURES: No relevant relationships by Nilofar Behbahani-Nejad No relevant relationships by Arshan Khan No relevant relationships by Warisha Khan No relevant relationships by Kanta Ukrani