Muhamed Saric, MD, PhD, FACC, FASE
New York University
Director, Echocardiography Lab
Associate Professor of Medicine

Intensive Care Medicine
Springer-Verlag 2001
DOI 10.1007/s00134-001-1171-8

Correspondence

Massive septic thrombus formation on a superior vena cava indwelling catheter following Torulopsis (Candida) glabrata fungemia

Monica T. Gressianu1, Vivek N. Dhruva1, Rohit R. Arora1, Sanjeev Patel1, Santos Lopez1, Ayad K. Jihayel2 and Muhamed Saric1, Contact Information

(1) Department of Medicine, New Jersey Medical School, 185 South Orange Avenue I-538, University Heights, Newark, NJ 07103, USA
(2) Department of Cardiothoracic Surgery, New Jersey Medical School, 185 South Orange Avenue G-595, University Heights, Newark, NJ 07103, USA
Contact Information E-mail: saricmu@umdnj.edu
Phone: +1-973-9726084
Fax: +1-973-9724737

Received: 22 October 2001 / Accepted: 26 October 2001 / Published online: 18 December 2001

Abstract. Fungal endocarditis is an exceedingly rare complication of indwelling central venous catheters in adults. Here we describe what appears to be the first case of a right atrial thrombus superinfected with the yeast Torulopsis (Candida) glabrata and attached to an indwelling superior vena cava catheter that was not used for parenteral nutrition. A large vegetation-like mass adherent to the catheter tip was visualized by transesophageal echocardiography in a patient who presented with signs of septic pulmonary embolism. Following open-heart surgery, the definitive diagnosis was established by histopathologic examination of the surgical specimen.

Sir: Fungal endocarditis is an exceedingly rare complication of indwelling central venous catheters in adults. Here we describe what appears to be the first case of a right atrial thrombus superinfected with the yeast Torulopsis (Candida) glabrata and attached to an indwelling superior vena cava catheter that was not used for parenteral nutrition.

Case report

A 48-year-old woman with a history of insulin-requiring diabetes mellitus and idiopathic thrombocytopenic purpura treated with splenectomy and intermittent oral prednisone was admitted to the hospital with a bacterial infection of her hip prosthesis.

Two months after initiation of long-term wide-spectrum antibiotic therapy via an indwelling central venous port catheter, she developed a sudden onset of shortness of breath. Her ECG revealed sinus tachycardia, right axis deviation and new T wave inversions in leads V1-3 suggestive of an acute right ventricular strain. A ventilation-perfusion scan suggested a high probability of pulmonary embolism. Transthoracic echocardiogram showed a dilated right heart, elevated pulmonary artery systolic pressure (45 mmHg) and a round mass in the superior portion of the right atrium. Multiplane transesophageal echocardiogram revealed a catheter in the superior vena cava with a large, highly mobile excrescence emerging from the catheter tip and extending deep into the right atrium (see Fig.1).

[Figure]

Fig. 1. Multiplane transesophageal echocardiogram in the vertical axis showing an indwelling catheter (CATH) in the superior vena cava (SVC). A large vegetation (VEG) attached to the tip of the catheter extends deep into the right atrium (RA). Histopathology of the surgical specimen revealed the mass to be a thrombus superinfected with the yeast Torulopsis (Candida) glabrata


The patient underwent open-heart surgery with successful removal of both the permanent catheter and the adherent friable irregular mass, which measured 3.2times1.2 cm. Microscopic examination of the surgical specimen revealed yeast colonies on a fibrin thrombus. Blood cultures drawn just prior to the surgery grew Torulopsis (Candida) glabrata. After intravenous amphotericin B therapy was initiated, there was a rapid sterilization of blood cultures and a complete resolution of clinical symptoms.

Discussion

Indwelling central venous catheters (ICVC) are used extensively to administer chemotherapy, parenteral nutrition and long-term antimicrobial therapy. In general, the rate of catheter-related complications is low. For instance, in a 5-year prospective study, the overall incidence of complications was 0.09 per 100 days. Most complications were due to either infection (0.02 per 100 days) or thrombosis (0.03 per 100 days) [1].

Superinfection of ICVC-related right atrial thrombi is not uncommon in children [2] but is exceedingly rare in adults [3, 4]. In the few reported cases of septic right atrial thrombi in adults, staphylococci and Candida albicans were the most commonly encountered microbial agents [5]. Aside from our patient, it appears that only two other cases of ICVC-adherent septic right atrial thrombosis due to Torulopsis (Candida) glabrata have been reported in English. In both patients the ICVC was used for total parenteral nutrition and in only one case was the infected thrombus visualized by echocardiography [6, 7]. Here we report what appears to be the first case of a right atrial thrombus infected by Torulopsis (Candida) glabrata and adherent to an indwelling central venous catheter not used for parenteral nutrition.

Torulopsis (Candida) glabrata is a low-virulence opportunistic pathogen that normally inhabits the skin and the mucosal surfaces of the oropharynx, gastrointestinal tract, urethra and vagina [8]. Most infections are nosocomial and the risk factors include immunosuppression, indwelling catheters, prolonged antibacterial treatment, diabetes mellitus and total parenteral nutrition [9]. The clinical spectrum of disease caused by Torulopsis (Candida) glabrata ranges from asymptomatic fungemia to life-threatening complications. In the case of septic right atrial thrombi, the potentially fatal complications include pulmonary embolism (as seen in our patient) and tricuspid valve obstruction [6]. Since the right atrial septic thrombi are often clinically silent, a high degree of suspicion is required for the correct diagnosis. Transesophageal echocardiography is an excellent imaging modality capable of visualizing the catheter and the adherent septic thrombus directly as well as its impact on surrounding cardiac structures.

When catheter-adherent right atrial septic thrombi are large, and thus prone to potentially life-threatening complications, a combination of surgical thrombectomy, catheter removal and prolonged antifungal treatment are the recommended forms of treatment [10].

References

1.Torramade JR, Cienfuegos JA, Hernandez JL, Pardo F, Benito C, Gonzalez J, Balen E, De Villa V (1993) The complications of central venous access systems: a study of 218 patients. Eur J Surg 159 (6-7):323-327

2.Paut O, Kreitmann B, Silicani MA, Wernert F, Broin P, Viard L, Camboulives J (1992) Successful treatment of fungal right atrial thrombosis complicating central venous catheterization in a critically ill child. Intensive Care Med 18 (6):375-376

3.Badano L, Carratino L, Giunta L, Calisi P, Lucatti A (1992) Infective right atrial thrombus: a rare complication of total parenteral nutrition in an adult. Eur Heart J 13 (10):1441-1443

4.Horner SM, Bell JA, Swanton RH (1993) Infected right atrial thrombus - an important but rare complication of central venous lines. Eur Heart J 14 (1):138-140

5.Kentos A, Dufaye P, Jacobs F, De Smet JM, Serruys E, Thys JP (1995) Candida albicans septic thrombosis of the right atrium is associated with a central venous catheter. Clin Infect Dis 21 (2):440-442

6.Chakravarthy A, Edwards WD, Fleming CR (1987) Fatal tricuspid valve obstruction due to a large infected thrombus attached to a Hickman catheter. JAMA 257 (6):801-803

7.Spapen H, Fiasse M, Diltoer M, Deuvaert FE, Huyghens L (1995) Catheter-related intracardiac thrombosis: a rare complication of Candida glabrata sepsis. Acta Clin Belg 50 (5):314-317

8.Fidel PL Jr, Vazquez JA, Sobel JD (1999) Candida glabrata: review of epidemiology, pathogenesis and clinical disease with comparison to C. albicans. Clin Microbiol Rev 12 (1):80-96

9.Chandler FW, Ajello L (1997) Torulopsosis. In: Connor DH et al. (eds) Pathology of infectious diseases. Appleton & Lange, Norwalk Conn pp 1105-1108

10.Kentos A, Thys JP (1996) Catheter-related intracardiac septic thrombosis. Acta Clin Belg 51 (1):63-64