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Antibacterials/caspofungin/milrinone Fatal infectious endocarditis secondary to Candida lusitaniae infection and lack of efficacy: case report

A 3-month-old boy developed fatal infectious endocarditis secondary to Candida lusitaniae infection during treatment with caspofungin, meropenem and vancomycin. Additionally, he exhibited lack of efficacy during treatment with milrinone for heart failure [dosages, routes and times to reactions onsets not stated]. The boy presented to a hospital in 2018 with underlying diagnoses of non-familial hypogammaglobulinaemia, persistent ductus arteriosus, cardiogenic shock, neonatal sepsis, chylothorax, moderate protein-caloric malnutrition, pulmonary hypertension due to arteriovenous fistula of pulmonary vessels and a satisfactory postoperative period of the surgery for transposition of the great vessels. The underlying conditions were managed on captopril, furosemide and spironolactone. On admission, vital sign measurement showed a heart rate of 153 beats per minute, respiratory rate of 39 breaths per minute, oxygen saturation level of 92%, body temperature of 36.8°C, body weight of 3240 grams, height of 60cm, nutritional assessment Z-score showed height-forage of -2 SD, weight-for-height of -2 SD, third percentile and weight-for-age of -2 DE. The chest examination showed normal expansion and visible emaciation. His paraclinical examination included haemogram with a mild anaemia. The echocardiogram revealed heart failure with a decreased ejection fraction, hence he was shifted to the paediatric ICU (PICU) for inotropic support with milrinone. However, on a hospital day 6, he showed clinical deterioration of the general and haemodynamic state along with the presence of signs of a systemic inflammatory response (lack of efficacy for milrinone), which was evident of a febrile peak of unknown focus. As a result, blood cultures were taken and management with vancomycin, meropenem and caspofungin was provided. The echocardiogram demonstrated fungal seeding in the right atrium and a high degree of embolisation (a size of 3mm in diameter), which did not require surgical approach. On 11 October 2018, blood cultures taken through a central venous catheter isolated Candida lusitaniae with sensitivity to azoles and echinocandins (including caspofungin). A diagnosis of infectious endocarditis secondary to Candida lusitaniae infection following vancomycin, meropenem and caspofungin use was made. The therapy with caspofungin was switched to fluconazole and treated with it for 42 days. In following days, he showed a favourable response. After 5 days, a follow-up echocardiogram showed an absence of fungal seeding. The underlying conditions led to prolongation of hospital admission for 3 months and then discharged. Unfortunately, he died due to severe malnutrition and complications from his multiple comorbidities. Portillo-Mino JD, et al. Infectious endocarditis due to Candida lusitaniae in an infant: A case report. [Spanish]. Infectio 24: 266-269, No. 4, 2020. Available from: URL: http:// 803