Aspergillus flavus mitral valve endocarditis after lung abscess

A 16-year-old male with bone marrow failure due to chemotherapy for recurre nt acute lymphoblastic leukemia developed an abscess in the lower lobe of t he left lung draining through a bronchogastric fistula, as well as mitral v alve endocarditis with large vegetations. After a course of antifungal ther apy, the left lobe was removed and the fistula closed. The mitral valve was then replaced, after a failed attempt at valve repair, by a mechanical, do uble-leaflet prosthesis. Microscopy of the lung and heart specimens disclos ed hyphae. Cultures of both specimens on Sabouraud's medium recovered a fun gus, which was identified by culturing on Czapek's medium as Aspergillus fl avus. Despite further antifungal therapy, fatal embolism developed. The emb oli contained the same A. flavus as the valve and lung specimens. This case confirms the grim prognosis of primary Aspergillus endocarditis in immunoc ompromised patients, and suggests that delayed surgical treatment and the p resence of another focus of Aspergillus infection may increase the risk of death.