Monica T. Gressianu¹, Vivek N. Dhruva¹, Rohit R. Arora¹, Sanjeev Patel¹, Santos Lopez¹, Ayad K. Jihayel² and Muhamed Saric^1,

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

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 V_1-3 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).

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

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