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Echohistological correlation in Candida albicans endocarditis

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A 28 year old man with a history of intravenous drug addiction was admitted to hospital with fever of 15 days duration and sudden pain in both legs. Physical examination showed a regular pulse of 130 beats/min and a diastolic murmur compatible with aortic regurgitation. Peripheral pulses were absent in both legs, which were cold and pale. Abdominal echography and computed tomography (CT) showed a mass obstructing the distal abdominal aorta as well as numerous splenic infarcts. The mass was extracted and cultured. Two days later the patient suddenly developed left sided weakness, and brain CT detected right parietal ischaemic infarction. Blood cultures were positive for Candida albicans.  Transoesophageal echocardiography showed a large vegetation (2.5 × 1 cm) attached to the aortic non-coronary cusp, and severe aortic regurgitation (AO aorta; LA, left atrium; LA, left ventricle; RV right ventricle). The vegetation was very mobile as demonstrated by comparing systole (left) and diastole (right). After a third embolism to the left leg the patient underwent surgery to excise the vegetation, and a bioprosthesis was implanted. On histological examination with periodic acid Schiff stain, typical yeast cells and pseudohyphae of Candida species were seen (below left). Methenamine silver stain clearly shows yeast and pseudohyphae elements of Candida species (below right). Amphotericin B (0.6 mg/kg/day) was given intravenously for four weeks. Cultures then became persistently negative. There were no other complications and the patient was discharged.