case report preterm caesarean delivery in a parturient with...

Case ReportPreterm Caesarean Delivery in a Parturient withCandida parapsilosis Endocarditis

Jason Fu,1 Lance M. Retherford,2 and Brigid Flynn3

1Department of Anesthesiology, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219, USA2Divisions of Cardiovascular Anesthesiology and Critical Care Medicine, The Permanente Medical Group, Inc.,San Francisco, CA 94115, USA3Anesthesiology and Critical Care, Kansas University Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA

Correspondence should be addressed to Brigid Flynn; [email protected]

Received 26 March 2015; Accepted 17 June 2015

Academic Editor: Neerja Bhardwaj

Copyright © 2015 Jason Fu et al.This is an open access article distributed under the Creative Commons Attribution License, whichpermits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

We present the first documented case of Candida parapsilosis infective endocarditis in a pregnant patient. While the incidence ofinfective endocarditis during pregnancy is rare, the incidence of C. parapsilosis endocarditis is even rarer. The numerous specificrisks and decision making processes regarding this case are presented.

1. Case Presentation

A 23-year-old female, gravida 1, and para 0 at 31 weeks ofgestation was transferred to our cardiothoracic intensive careunit (CTICU) for further management of her aortic valveendocarditis. Her past medical history included intravenousdrug use (currently on methadone maintenance), hepatitis Cdiscovered during this pregnancy, bipolar disorder, anddepression with multiple prior suicide attempts. Of note, thepatient also had a root canal two weeks prior and was startedon ampicillin for a dental abscess.

She initially presented to an outside hospital one weekearlier with severe right thigh and groin pain, which had pro-gressed to the point of inhibiting ambulation. A right lowerextremity Doppler study revealed an occlusive thrombus inthe deep femoral artery. She was started on therapeutic enox-aparin and transferred to a second hospital, where a transtho-racic echocardiogram (TTE) revealed large vegetative lesionson all 3 leaflets of the aortic valve, including a mobilevegetation measuring 0.8-1-cm on the ventricular side of thevalve (Figures 1–3). Mild tomoderate aortic insufficiency waspresent. Blood cultures grew yeast but had not yet speciatedupon transfer to our hospital. Amphotericin B was initiatedand, after an initial infusion reaction, she was able to tolerate

subsequent doseswith premedication.Micafunginwas addeduntil speciation of the yeast was final. She remained hemody-namically stable requiring no inotropic or pressor support.

Anticoagulation was withheld despite her thrombus dueto concern for cerebral embolic infarction and risk of hemor-rhagic conversion in the setting ofmobile aortic endocarditis.A magnetic resonance angiogram (MRA) of the brain wasobtained to rule out amycotic aneurysm, given that her endo-carditis was known to be fungal in nature. The MRA showeda 2.2mmaneurysm of the anterior communicating artery. Anophthalmologic examwas negative for fungal endophthalmi-tis. She received betamethasone and magnesium sulfate forfetal lung maturity and fetal neuroprotection, respectively. Afetal ultrasound demonstrated normal growth and activity ofthe fetus.

After a multidisciplinary meeting involving the CTICUintensivists, obstetrics, cardiothoracic surgery, cardiology,neurology, neurosurgery, obstetric anesthesiology, and obste-tric and CTICU nursing teams, it was decided to proceedwith delivery of the baby via Caesarean section followed by anaortic valve replacement (AVR) the following day. The deci-sion to separate the procedures by approximately 12 hourswasmade out of concern for uterine bleeding after the Caesareansection with the full heparinization required for the AVR.

Hindawi Publishing CorporationCase Reports in AnesthesiologyVolume 2015, Article ID 897645, 4 pageshttp://dx.doi.org/10.1155/2015/897645

2 Case Reports in Anesthesiology

Figure 1: 2D aortic valve short-axis, transesophageal view display-ing fungal vegetation on all three aortic valve leaflets.

It was decided that the risk of significant uterine bleeding,possibly necessitating a hysterectomy, would be too high in a23-year-old woman.

The following day, the patient underwent a successfulCaesarean delivery of a healthy baby under general endotra-cheal anesthesia. Her trachea was extubated so that she couldspend time with her newborn. The following morning, sheunderwent a bioprosthetic AVR and a right femoral arterythrombectomy. Her blood cultures eventually speciated toCandida parapsilosis, as did intraoperative cultures.

It was decided that the patient would need long termantifungal therapy for her endocarditis and fungemia and thata peripherally inserted central catheter (PICC) was indicated.Initially there was a great deal of hesitation to place a PICCand possibly discharge her with one, given her history ofintravenous drug abuse. Although there was no evidence ofrecent intravenous drug use, both on physical exam and onmultiple urine toxicology screens, ethics and psychiatric con-sultations were obtained. After much deliberation, it wasdecided that PICC placement should not be withheld fromher if it was medically indicated.

Discussions concerning whether the patient needed fur-ther brain imaging or intervention at some point for heraneurysm also took place. However, on further review of theMRA, the neurology service decided that based on its appear-ance and location the aneurysm was most likely congenitaland not mycotic. Thus, no further imaging was warranted.

Postoperatively, the patient experienced considerablepostsurgical pain that was difficult to control initially, likelydue to her increased opiate requirements. In addition to hermaintenance methadone dosing and a hydropmorphonePCA, she was maintained on fentanyl, ketamine, and dexme-detomidine infusions, which were gradually able to beweaned off over the next few days as her pain improved. Theketamine and dexmedetomidine infusions provided a mul-timodal and narcotic sparing approach to her opiate tolerantpain. Shewas eventually discharged from theCTICUonpost-operative day 3 and from the hospital on postoperative day 17.

2. Discussion

As of 2007, there have been only 72 cases of Candida para-psilosis endocarditis documented [1]. Infective endocarditisduring pregnancy is extremely rare as well, with an incidenceof only 0.006% [2]. To the authors’ knowledge, this is firstcase report ofCandida parapsilosis endocarditis in a pregnantwoman documented to date.

The maternal mortality rate with infective endocarditisduring pregnancy can reach 33%, with most deaths relatedto heart failure or an embolic event (cerebral, coronary, orpulmonary).The rate of fetalmortality can reach 29%. In gen-eral, infectious endocarditis differs between intravenous drugabusers and nonusers in the fact that most intravenous drugabusers do not have underlying cardiac structural defects.Thus, the tricuspid valve is most commonly infected and thecausative agent is usually Staphylococcus aureus. In patientswith underlying structural cardiac defects, infectious endo-carditis usually involves the left side of the heart and is causedby low-virulence bacteria, such as Staphylococcus epider-midis, Streptococcus viridans, and Streptococcus faecalis [3].Although our patient had no underlying structural cardiacabnormality andwas an intravenous drug abuser, she unchar-acteristically developed fungal aortic valve endocarditis.

Candida is the most common cause of fungal endocardi-tis, with Candida parapsilosis being the most prevalent typeof nonalbicans species isolated [4]. The most common pre-disposing factor for Candida parapsilosis endocarditis is thepresence of prosthetic valves. The most common risk factorfor infection of native valves is a history of intravenous druguse [1]. Candida parapsilosis endocarditis carries high mor-bidity and mortality rates. Cerebral and peripheral embolicevents occur in over 40% of patients, and overall mortality isover 40%. Lower mortality rates can be achieved with com-bined surgical and medical therapy, which underscores theimportance of early diagnosis and multimodal treatment [1].

This case brings to light several issues concerning theparturient with cardiovascular disease. Much considerationwent into the timing of the two necessary surgical proceduresin this case. Consideration of performing only the AVR andallowing gestation to continue for several days toweekswouldprovidemore time for pulmonarymaturation.This techniquehas been used with success during the first reported case ofmaternal infective endocarditis [4]. In that case, an AVR wasperformed at 22 weeks of gestation and the baby was notdelivered until term. However, subsequent reports were notas favorable. Montoya et al. documented a case of infectiveendocarditis in a patient who was 11 weeks of gestation andunderwent an AVR.The patient fared well; however, the fetusdied in utero [2]. In our case, we felt the risks imposedupon a fetus due to rapid hemodynamic changes and hypo-thermia during cardiopulmonary bypass would imposemoresignificant risk than birth at 31 weeks of gestational age.

As far as performing the procedures concomitantly, therisk of uterine bleeding with the anticoagulation requiredfor cardiopulmonary bypass is a concern. The treatment formassive uterine bleeding is ultimately a hysterectomy andin a young female, this risk has serious consequences. Forthis reason, it was decided that the AVR should occur after

Case Reports in Anesthesiology 3

(a) (b)

Figure 2: 3Dmidesophageal aortic valve short-axis view. In (a), the valve is opening. Note the vegetation on all three leaflets. In (b), the valveis closed and vegetation can be seen obstructing the point of coaptation.

Figure 3: 2Dmidesophageal aortic valve long axis with notable largevegetation.

the Caesarean by several hours, allowing for evaluation ofuterine bleeding via CTICU monitoring and an abdominaldrain. Furthermore, waiting several hours allowed for assess-ment of mental status prior to the AVR in case of an embolicevent. However, other authors have reported success with amitral valve repair on the same day as a 33-week gestationalCaesarean section in a patient with mitral valve endocarditiswith no untoward events [5].

The obstetric anesthesia team involved decided the pat-ient’s fungemia and her recent systemic anticoagulation at theoutside hospital for her deep femoral artery thrombosis werecontraindications to neuraxial anesthesia. However, withoutany neuraxial anesthesia in place, there was concern thatthe potential hypertension and tachycardia associated withvaginal delivery would increase the risk of embolization ofthe vegetation with dire consequences. Additionally, it wasfelt that induction and trial of labor would only increase riskof cardiac dysfunction in the setting of aortic insufficiency.

These risks were weighed heavily with the final decision elect-ing for general endotracheal anesthesia as the safest measure.Her postoperative pain control was also an area of importancein this opiate tolerant patient and a multimodal analgesicapproach consisting of her home methadone dosing, otheropiates, and, importantly, ketamine and dexmedetomidinefor the narcotic sparing properties of these agents [6].

3. Summary

This case describing a preterm parturient with Candida para-psilosis endocarditis illustrates that cardiac disease in theparturient can be managed safely. However, managementrequires amultidisciplinary team approach thatmust be indi-vidualized for each patient. In this case, we proceeded withCaesarean delivery of the fetus at 31-week gestational age,monitored the patient overnight, and then proceeded to anaortic valve replacement. While this patient did very well,each institution must weigh the numerous risks and benefitsinvolving two patients (mother and baby) when makingclinical decisions in cases of cardiac disease in the parturient.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

References

[1] C. Garzoni, V. A. Nobre, and J. Garbino, “Candida parapsilosisendocarditis: a comparative review of the literature,” EuropeanJournal of Clinical Microbiology & Infectious Diseases, vol. 26,no. 12, pp. 915–926, 2007.

[2] M. E. Montoya, B. M. Karnath, and M. Ahmad, “Endocarditisduring pregnancy,” Southern Medical Journal, vol. 96, no. 11, pp.1156–1157, 2003.

4 Case Reports in Anesthesiology

[3] S. M. Cox, G. D. V. Hankins, K. J. Leveno, and F. G. Cunning-ham, “Bacterial endocarditis. A serious pregnancy complica-tion,” Journal of Reproductive Medicine for the Obstetrician andGynecologist, vol. 33, no. 7, pp. 671–674, 1988.

[4] M. Nazarian, G. H. McCullough, and D. L. Fielder, “Bacterialendocarditis in pregnancy: successful surgical correction,” Jour-nal of Thoracic and Cardiovascular Surgery, vol. 71, no. 6, pp.880–883, 1976.

[5] K. Kongwattanakul, S. Tribuddharat, S. Prathanee, and O.Pachirat, “Postcaesarean open-heart surgery for Streptococcussanguinis infective endocarditis,” BMJ Case Reports. In press.

[6] O. Panzer, V. Moitra, and R. N. Sladen, “Pharmacology ofsedative-analgesic agents: dexmedetomidine, remifentanil,ketamine, volatile anesthetics, and the role of peripheral Muantagonists,” Anesthesiology Clinics, vol. 29, no. 4, pp. 587–605,2011.

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