Pediatric Fungal Endocarditis: An Overview

Introduction:

Pediatric fungal endocarditis is a rare and serious condition characterized by fungal infection of children's heart’s inner lining or valves. It typically occurs in children with underlying health conditions or weakened immune systems. Candida and Aspergillus are common fungal species involved. Treatment usually involves antifungal medication and, in some cases, surgery to repair or replace damaged heart valves. Early diagnosis and prompt treatment are essential for a better prognosis.

What Is Fungal Endocarditis?

Endocarditis is the inflammation of the inner layer of the heart and heart valves called the myocardium. Usually, it is caused by bacteria called infective endocarditis. If it is caused by a fungal infection called the fungal endocarditis. Fungal endocarditis can present as inflammation of the endocardial surface or device-related infective endocarditis.

What Could Be the Pathophysiology of the Pediatric Fungal Endocarditis?

The species of Candida and Aspergillus cause fungal endocarditis. These fungi enter the bloodstream through infections or from any surgical procedures and lodge inside the walls of the heart valves or the heart (endocardium). The lodged fungus then multiplies and forms vegetation in the weak areas that disturb the heart’s normal functions. This happens in children with weakened immune systems or with any underlying diseases.

What Are the Signs and Symptoms of Pediatric Fungal Endocarditis?

The signs and symptoms of pediatric fungal endocarditis depend on the type of fungus involved and the location of the infection. Common signs and symptoms include

• Fever.

• Fatigue.

• Loss of appetite.

• Weight loss.

• Persistent cough.

• Difficulty breathing.

• Skin rashes.

• Oral thrush (white patches in the mouth).

• Nasal congestion.

• Neurological symptoms like headache, confusion, and seizures.

• Enlarged lymph nodes.

Who Is Susceptible to Pediatric Fungal Endocarditis?

Risk factors for pediatric fungal endocarditis include:

• Children with congenital heart defects (defects present since birth), especially when with prosthetic valves.

• A weakened immune system increases the risk of fungal diseases.

• Children requiring long-term intravenous catheters for chemotherapy or parenteral nutrition have an increased risk for bloodstream infections.

• Invasive medical intervention or dental treatment can increase the risk of fungal infection.

• Malnutrition and premature infants with underdeveloped immune systems increase the risk of fungal infections.

• Long-term use of antibiotics paves the way for the increase in the chances of the proliferation of fungus.

How Is Pediatric Fungal Endocarditis Confirmed?

The diagnostic tests involve a thorough clinical examination, imaging studies, and blood tests.

• Clinical Evaluation: The healthcare provider gets a detailed history of previous infections or surgical procedures.

• Blood Cultures: Blood samples are collected to get the culture done to confirm the presence of fungi in the bloodstream. Multiple cultures are done as fungi are difficult to isolate.

• Imaging Studies: Echocardiography (cardiac ultrasound), including transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE), is essential for visualizing the heart structures and detecting abnormalities such as vegetations on the heart valves or intracardiac abscesses.

• Histopathological Examination: If the child undergoes surgery to repair or replace damaged heart valves, tissue samples obtained during the procedure may be examined under a microscope to confirm the presence of fungal infection and identify the specific fungal species involved.

Additionally, certain common blood tests like complete blood count (CBC), C. reactive protein, and erythrocyte sedimentation rate (ESR) are done. Due to its rarity, diagnosis may be challenging. So, prompt medical intervention is needed to prevent complications.

How Is Pediatric Fungal Endocarditis Treated?

The treatment of pediatric fungal endocarditis typically involves a combination of antifungal medications and, in some cases, surgical intervention. Here is an overview of the treatment approach:

Antifungal Therapy: The primary treatment for fungal endocarditis involves the administration of antifungal medications to eradicate the fungal infection. The choice of antifungal agent depends on the specific fungal species identified and its susceptibility to antifungal drugs. Commonly used antifungal medications include:

• Amphotericin B: A broad-spectrum antifungal medication often used as initial therapy for severe fungal infections.

• Fluconazole: An azole antifungal medication that is effective against Candida species and is often used for less severe cases or long-term maintenance therapy.

• Voriconazole: Another azole antifungal agent that is active against Aspergillus species and may be used in cases of Aspergillus endocarditis.

Surgical Intervention: In cases of severe valve damage, persistent infection despite antifungal therapy, or complications such as heart failure or embolic events, surgical intervention may be necessary. Surgical options may include:

• Valve Repair: Surgical repair of damaged heart valves to restore normal function.

• Valve Replacement: Surgical removal of infected heart valves followed by replacement with mechanical or biological prosthetic valves.

• Debridement: Removal of infected tissue and debris from the heart valves or surrounding structures to reduce the fungal burden and improve outcomes.

Supportive measures such as intravenous fluids, electrolyte balance, and nutritional support are necessary to maintain overall health. Long-term monitoring is necessary to check for recurrence of infection and the function of prosthetic valves.

Treatment decisions should be individualized based on the child’s clinical presentation, underlying health conditions, the severity of the infection, and the availability of resources.

Does Pediatric Fungal Endocarditis Pose Any Complications?

If pediatric fungal endocarditis is left untreated or not managed properly, it could lead to

• Heart valve damage like narrowing of the valves or leakage of the blood backward.

• Formation of embolism happens, and the chances of the embolus fragments getting into the circulation are high, and they can lodge in any organs, causing organ damage.

• Severe damage to the heart valves can impair heart pumping ability, leading to heart failure.

• Fungal infections can lead to abscesses in the heart valves that can compromise heart function.

• Fungal infection can lead to sepsis - a life-threatening condition where there is widespread inflammation and organ dysfunction.

In What Ways Was Pediatric Fungal Endocarditis Prevented?

• Preventing fungal endocarditis in children primarily involves addressing underlying risk factors, such as congenital heart defects or immunocompromised conditions.

• Prophylactic antibiotics before certain medical procedures may also be considered, although their efficacy in preventing fungal endocarditis specifically is debated.

• Regular dental care and hygiene maintenance can help reduce the risk of oral fungal infections, which can sometimes lead to endocarditis.

• Consulting with pediatric cardiologists and infectious disease specialists for personalized prevention strategies is essential.

Conclusion:

Pediatric fungal endocarditis is a rare, serious, life-threatening condition that is challenging to diagnose and poses severe complications if left inadequately managed. Timely intervention is needed to prevent the complications and to preserve the heart function. Long-term follow-up is mandatory to catch up with the remission. A multidisciplinary collaboration involving cardiologists, cardiothoracic surgeons, and pediatric specialists is needed for optimal management.