CASE REPORT Aspergillus cyst of aortic valve bioprosthesis Ashraf M. Anwar • Youssef F. M. Nosir • Mirvat Al-Asnaj • Walid Abukhudair • Abdullah Ashmeg • Hassan Chamsi-Pasha Received: 26 October 2010 / Revised: 1 December 2010 / Accepted: 2 December 2010 / Published online: 2 February 2011 Ó Japanese Society of Echocardiography 2011 Abstract Aspergillus endocarditis (AE) is an ominous complication of cardiac surgery with a dismal prognosis. We present a 35-year-old female who developed AE 4 months after her aortic and mitral valve replacement. Transesophageal echocardiography revealed an aortic root abscess and a cystic mass attached to the aortic biopros- thesis. Intraoperatively, the cyst was filled with fungal material. The aortic bioprosthesis was replaced and the patient was treated with amphotericin B. Six weeks later her condition suddenly deteriorated and she died on the same day. Early performance of transesophageal echocar- diography and extended blood culture is mandatory in suspected cases of AE. Keywords Aspergillosis Á Aortic valve Á Endocarditis Á Vegetation Á Abscess Á Echocardiography Background Aspergillus endocarditis (AE) is a highly challenging ominous condition because of difficulty in detection of the source, establishment of the diagnosis, and treatment [1]. AE typically develops in patients with valvular risk factors (previous valve surgery, infective endocarditis, rheumatic heart disease, mitral prolapse) and medical risk factors (malignancy, central venous catheters, and prolonged use of antibiotics [2]. Moreover, the presence of Aspergillus in operating room air-conditioning can lead to intraoperative contamination by airborne spores [1]. Blood culture usually remains negative even with extensive disease [2, 3]. We report a case of fulminant AE in an immunocompetent. Case report A 35-year-old female with rheumatic valvular disease had bioprosthetic mitral and AV replacement with satisfactory function. One month later, she presented with fever, chills, and fatigue and treated as culture-negative endocarditis with teicoplanin and meropenem for 6 weeks. She responded well and was discharged in good condition. She was readmitted 6 weeks later with a 5-day history of fever (39.6°C). A new systolic murmur was noted with no evidence of embolization. She had a white blood cell count of 7.4 9 10 9 /l, erythrocyte sedimentation rate (ESR) 36 mm/h, C-reactive protein (CRP) level 177 mg/l, and negative blood cultures. Two-dimensional echocardiography (2DE) showed normally functioning mitral valve bioprosthesis and an ejection fraction of 60%. The aortic root appeared dense with increased thickness of aortic bioprosthesis leaflets and a peak gradient of 40 mmHg. Transesophageal 2DE (TEE) revealed thickened aortic wall with a large posterior aortic root abscess (11 mm) (Fig. 1a; movie 1 in electronic supplementary material). A cystic mass measuring 12 mm in diameter containing small cavities was seen attached to the non-coronary leaflet of the AV bioprosthesis. Multiple small vegetations were also noted on the bioprosthesis with no evidence of valve dehiscence (Fig. 1b, movie 2 in electronic supplementary Electronic supplementary material The online version of this article (doi:10.1007/s12574-010-0079-0) contains supplementary material, which is available to authorized users. A. M. Anwar Á Y. F. M. Nosir Á M. Al-Asnaj Á W. Abukhudair Á A. Ashmeg Á H. Chamsi-Pasha (&) Department of Cardiology, King Fahd Armed Forces Hospital, P.O. Box 9862, Jeddah 21159, Kingdom of Saudi Arabia e-mail: drhcpasha@hotmail.com 123 J Echocardiogr (2011) 9:117–118 DOI 10.1007/s12574-010-0079-0