P19. Endocarditis caused by Aspergillus Species in newly diagnosed HIV patient with normal CD4+ cell count. Case report.

Monta Madelane1,2, Anastasija Sangirejeva1,2, Elina Kale1,2, Gunta Sture1,2, Baiba Rozentale1,2

Affiliates: 1Riga East Clinical University hospital, 2hospital “Infectology center of Latvia Riga Stradins University

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Aspergillus species are the most frequently isolated molds among HIV infected patients, but invasive aspergillosis is very uncommon in this population. In HIV infected persons, invasive aspergillosis usually occurs in patients with CD4+ T cell count less than 50 cells/µL , and in those with neutropenia or on corticosteroids. Invasive aspergillosis most frequently affects the respiratory tract, the CNS, and the eyes. Aspergillus endocarditis is, accordingly, quite rare manifestation of invasive aspergillosis, usually in injection drug users (IDUs), both those with and those without HIV infection.

Case description
63 years old woman was hospitalized due to complains of progressive dyspnea, leg edema. Symptoms were lasting for 1,5 month, gradually progressed, worsened during last week before admission. Vital signs on admission were: temperature 36.20C, blood pressure of 120/75 mmHg, heart rate 110 beats/min, respiratory rate of 26 breaths/min. There are no data for heart tones from the first admission. Complete blood count showed white blood cells 11.200/mm3, platelet count of 135.000/mm3, C-reactive protein 30 mg/L, D- dimers 7.61 mg/L.
She had no history of intra venous drug usage, no chronic disorders, alcohol consumption once a week, many abortions.
Chest computer tomography (CT) was performed in order to rule out pulmonary embolism (PE). CT indicated pulmonary congestion, bilateral hydrothorax, and air filled cavity in the right central lobe (diameter 5 cm), most probably bullous lesion. There was no evidence of PE. Echocardiogram showed serious aortal regurgitation, large vegetation (2,5 cm) on aortic valve, signs of pulmonary hypertension. Diagnosis of septic endocarditis was made. Patients’ blood cultures were negative for bacteria and fungi. The patient was treated empirically with broad spectrum antibiotics.
Cardiac surgery was performed on 11th day after admission with aortic and mitral valve replacement, and tricuspid valve repair. Surgical material culture was positive for Aspergillus spp. Her HIV status first was discovered only after surgery. Following tests showed: CD4+ T cell count was 861 cells/µL, HIV RNA- 49 copies/ml. There was no evidence of other opportunistic infections: blood culture- sterile, in blood: Cryptococcus neoformans antigen, Candida antigen, Aspergillus antigen- negative.
Patient received long term treatment with Voriconazole and Amphotericin B lipid complex.
Due to high level of CD4+ T cell count no antiretroviral treatment (ART) was initiated.
Year after HIV diagnosis was made patient is still without ART, her CD4+ T cell count has increased – 1195 cells/µL.

Diagnosis of Aspergillus endocarditis should be pursued in HIV patients, especially IDUs, with negative blood cultures and large valvular vegetations. There is still no consensus of the appropriate length of antifungal therapy in case of Aspergillus endocarditis.