In a patient with candidemia, should an echocardiographic evaluation be performed to assess for cardiac vegetations?

Echocardiography for Candidemia: Essential for Detecting Cardiac Vegetations

Yes, echocardiographic evaluation should be performed in all patients with candidemia to assess for cardiac vegetations, as Candida infective endocarditis (CIE) occurs in approximately 4-6% of candidemic patients and is frequently clinically unsuspected. 1, 2

Incidence and Clinical Significance

• CIE occurs in 4.2-5.9% of all candidemic patients, making it more common than historically recognized 2
• At least 27% of CIE cases are clinically unsuspected at the time of diagnosis, meaning they would be missed without systematic echocardiographic screening 2
• Fungal endocarditis carries the highest mortality among all causes of infective endocarditis, with 90-day mortality approaching 48.9% 1, 3, 4
• Surgery is indicated for fungal endocarditis due to the low likelihood of antimicrobial control alone 1

Guideline Recommendations

• Transoesophageal echocardiography (TEE) should be performed to detect organ involvement in patients with candidemia 1
• Echocardiography is fundamental for detecting cardiac complications in patients with candidemia and/or disseminated candidiasis 1
• Both TTE and TEE are recommended as complementary investigations, with TEE having superior sensitivity 1

Diagnostic Approach Algorithm

Initial Imaging Strategy

• Start with transthoracic echocardiography (TTE) as the first-line imaging modality in all candidemic patients 1, 5
• TTE sensitivity is approximately 75% for detecting vegetations, identifying only 2.9% of CIE cases in one prospective study 5, 2

When to Proceed to TEE

• Perform TEE in all candidemic patients who are suitable candidates and can tolerate the procedure 1, 2
• TEE has 11.5% positivity rate among candidemic patients who undergo the study, significantly higher than TTE 2
• TEE sensitivity approaches 85-90% for detecting vegetations, with approximately 99% sensitivity for native valve endocarditis 5

High-Risk Features Requiring Immediate TEE

• Pre-existing valvular heart disease (adjusted OR 7.66 for CIE) 4
• Prosthetic valves or cardiac devices (TEE sensitivity 90% vs. TTE 50%) 5
• Persistent candidemia despite appropriate antifungal therapy 1
• New cardiac murmur or signs of heart failure 1

Characteristic Echocardiographic Features of CIE

Vegetation Characteristics

• Large, dense, heterogeneous vegetations are the hallmark finding in 92% of CIE cases (11/12 patients) 6
• Vegetations are typically >10 mm and carry high embolic risk 1, 5
• Mobile masses attached to valvular structures appear as echogenic material 5

Myocardial Involvement

• Hyperechogenic heterogeneous myocardial texture is seen in 58% of CIE cases (7/12 patients) and indicates extensive myocardial damage 6
• This finding is relatively specific for Candida species endocarditis and warrants early surgical intervention 6

Valvular Complications

• Valve perforation, dehiscence, and severe regurgitation are common findings 5
• Perivalvular abscesses appear as thickened, non-homogeneous areas 5

Clinical Predictors That Modify Testing Strategy

Factors Associated with LOWER Risk of CIE

• C. glabrata infection (adjusted OR 0.17) - these patients may have lower priority for immediate TEE 4
• Hematologic malignancy (adjusted OR 0.09) 4
• Receipt of total parenteral nutrition (adjusted OR 0.38) 4

Critical Caveat

Even in lower-risk patients, echocardiography should still be strongly considered given the high mortality of missed CIE and the frequency of clinically unsuspected cases 2

Timing Considerations

• Perform echocardiography as soon as candidemia is documented, ideally within 24-48 hours 1
• Do not delay antifungal therapy while awaiting echocardiography 1
• If initial TEE is negative but clinical suspicion remains high, repeat TEE after 3-10 days 5
• Serial echocardiography is indicated if fever persists despite appropriate therapy or new cardiac symptoms develop 5

Common Pitfalls to Avoid

• Do not rely solely on blood cultures - three consecutive blood cultures were negative in one confirmed case of CIE diagnosed by surgical specimen 7
• Do not assume absence of cardiac symptoms excludes CIE - the disease is frequently clinically unsuspected 2
• Do not accept a negative TTE as definitive - TEE detected CIE in 11.5% of patients when TTE was negative or equivocal 2
• Do not delay surgical consultation if vegetations are identified, as medical therapy alone has high mortality 1

Management Implications of Positive Findings

• Initiate echinocandin therapy (micafungin, caspofungin, or anidulafungin) as first-line treatment 1, 3
• Consult cardiothoracic surgery immediately for consideration of valve replacement 1, 6
• Extend antifungal therapy duration to at least 4-6 weeks, with at least 2 weeks after device/valve removal 1
• Perform fundoscopy to evaluate for ocular candidiasis as part of comprehensive assessment 1