When Lightning Strikes Twice: Acute Ischemic Stroke and Intracranial Hemorrhage in a Patient with Candida Endocarditis
Justine Chee1, Kangni Xiao1, Nabihah Kabir2, Jared Davis2, Mariyam Humayun2, Ciro Ramos Estebanez2, Gursant Atwal3, Faten El Ammar2
1Neurology, 2Neurocritical Care, 3Neurosurgery, University of Illinois at Chicago
Objective:
To describe a rare case of repeated intracranial pathologies secondary to fungal endocarditis.
Background:
It is estimated that about 2-4% of patients with infectious endocarditis (IE) develop mycotic aneurysms (MA), which typically occur about two months after IE diagnosis. Approximately 50% or more intracranial MA’s rupture, which carries a high mortality rate up to 80%. Fungal endocarditis comprises about 1-3% of total infectious endocarditis cases. There is limited research on clinical outcomes or surveillance imaging guidelines for mycotic aneurysms, particularly in the setting of fungal endocarditis.
Results:
A 45 year-old male with rheumatoid arthritis on prednisone presented to the emergency room with dizziness. Brain imaging revealed multifocal punctate infarcts. Work-up for embolic stroke revealed candidemia with a bicuspid aortic valve vegetation. His hospital course included IV antifungals, prosthetic valve replacement, therapeutic anticoagulation initiation, and digital subtraction angiography (DSA), which was negative for aneurysm. Three months later, on maintenance antifungal therapy, he presented with acute left hemiparesis and hemihypoesthesia. Imaging showed a large right parenchymal intracerebral hemorrhage with intraventricular hemorrhage. Work-up revealed persistent candidemia now complicated by prosthetic aortic valve endocarditis. Emergent DSA demonstrated a ruptured 1-mm distal right pericallosal artery aneurysm, thereafter treated endovascularly with glue embolization. Over the subsequent few weeks, the patient demonstrated progressive neurological improvement. He was continued on antifungal therapy pending definitive treatment of IE by cardiothoracic surgery.
Conclusions:
This case illustrates a rare and complex situation involving repeat neurologic complications of fungal IE. While the initial presentation included multiple cerebral ischemic infarcts, the patient developed an intracranial parenchymal hemorrhage from a de novo mycotic aneurysm 3 months after treatment with appropriate antifungal therapy. Given that MA’s typically develop within a few weeks to months of IE, we suggest interval surveillance vascular imaging in IE patients to facilitate early detection and timely management of MA prior to rupture.
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