Abstract Details

Title When Lightning Strikes Twice: Acute Ischemic Stroke and Intracranial Hemorrhage in a Patient with Candida Endocarditis

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) P11 - Poster Session 11 (11:45 AM-12:45 PM)

Poster/Presentation
Number 5-009

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.

Design/Methods N/A

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.

Authors/Disclosures
Justine Chee, MD PRESENTER	Dr. Chee has nothing to disclose.
Kangni Xiao, MD	Dr. Xiao has nothing to disclose.
Nabihah Kabir, MD (University of Illinois)	Dr. Kabir has nothing to disclose.
Jared M. Davis, MD (University of Illinois, Chicago)	Dr. Davis has nothing to disclose.
Mariyam Humayun, MD	Dr. Humayun has nothing to disclose.
Ciro Ramos Estebanez, MD, PhD, MBA, FAAN (University of Illinois in Chicago)	The institution of Dr. Ramos Estebanez has received research support from NIH. Dr. Ramos Estebanez has received intellectual property interests from a discovery or technology relating to health care.
Gursant Atwal (UIC)	Gursant Atwal has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Aesculap.
Faten El Ammar, MD (University of IL, Chicago)	Dr. El Ammar has nothing to disclose.

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