title: Recurrent candida prosthetic endocarditis over fifteen years managed with medical therapy and four valvular surgeries: a case report and review of literature.
abstract: BACKGROUND
  Candida prosthetic endocarditis (CPE) is an uncommon disease involving less than 1 % of infective endocarditis patients and associated with high recurrence rate. Immunosuppresion, intravenous drug abuse, cardiac surgery and indwelling foreign bodies are the major risk factors for CPE. There are very few reported cases of CPE where more than one surgery was performed and there has generally been limited follow up on these cases.
  
  
  METHODS
  We report a case of a 35 year old woman who had mitral valve annuloplasty complicated by recurrent episodes of CPE leading to multiple mitral valve replacements (MVR). She underwent MVR surgeries a total of four times over an eighteen year period and had good functionality during most of this time while being on antifungal suppressive treatment. This is a unique case in terms of numbers of surgeries performed, the length of the follow up and the involvement of three different Candida species.
  
  
  CONCLUSIONS
  Current guidelines for the treatment of candida endocarditis recommend surgical treatment followed by long term antifungal therapy although the cure rate by all treatments is low. However we feel that based on this one case it is reasonable to consider multiple redo valve replacement surgeries in conjunction with antifungal treatment for selected patients stable enough to tolerate the surgery.
authors.affiliation: Department of Medicine, West Virginia University, Charleston Division, Charleston, WV, USA. bidhakal@hsc.wvu.edu.
authors.forename: Bishnu P
authors.initials: BP
authors.lastname: Dhakal
authors.affiliation: Cardiothoracic Surgery, University of Virginia, Charlottesville, VA, USA. CGT2E@hscmail.mcc.virginia.edu.
authors.forename: Curtis G
authors.initials: CG
authors.lastname: Tribble
authors.affiliation: Cardiology Division, University of Virginia, Charlottesville, VA, USA. JDB5R@hscmail.mcc.virginia.edu.
authors.forename: James D
authors.initials: JD
authors.lastname: Bergin
authors.affiliation: West Virginia School of Osteopathic Medicine, Charleston, WV, USA. swinfrey@osteo.wvsom.edu.
authors.forename: Sean
authors.initials: S
authors.lastname: Winfrey
authors.affiliation: Cardiology Division, West Virginia University, Charleston Division, Charleston, WV, USA. williamcarterwv@gmail.com.
authors.forename: William H
authors.initials: WH
authors.lastname: Carter
mesh_terms: D000328:Adult; D000935:Antifungal Agents / Q000627:therapeutic use*; D002177:Candidiasis / Q000175:diagnosis / Q000382:microbiology / Q000628:therapy*; D004697:Endocarditis, Bacterial / Q000175:diagnosis / Q000382:microbiology / Q000628:therapy*; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D016459:Prosthesis-Related Infections / Q000175:diagnosis / Q000382:microbiology / Q000628:therapy*; D012008:Recurrence
chemical_list: D000935:Antifungal Agents