Tiny Heart, Big Challenge !!!!

Dr.SreeLekshmy.S, Dr.Jayasree, Dr.Brijesh,DrC Jayakumar 
Expreterm ba was born at 31 weeks to a G2A1 mother on 4/8/24 with a Birth weight of 1.93 kg Ba and had NICU stay of 10 days in an outside hospital. Ba was started on CPAP and weaned to room air day 21 pf life. Blood culture sent during the course of hospital stay showed growth of Candida albicans and ba was given fluconazole for 10days. 
ECHO done on day 2 of life showed a tiny ASD(2.5mm) and a closing PDA. 
Repeat ECHO done on day 18 of life showed a intracardiac mass attached to interatrial septum 8 x 6 mm, towards left atrium. 
Repeat ECHO done at one month of life showed two pedunculated mass in the left atrium(13×5.4) and right atrium(5.6x8mm) arising from the interatrial septum, 
?Atrial myxoma. Ba was referred to AIMS for further management.
At admission, ba was on room air with stable vitals. 
Systemic examination was within normal limits. 
ECHO showed pedunculated(11×3.1mm) mass in left atrium attached to mid  interatrial septum with additional sessile mass(7.1 x 4.1mm) on posterior/ superior aspect of right atrium. Mass was removed and ASD patch repair was done on day 6 of admission.  Gram stain from interatrial mass showed budding yeast. Hence ba was started on Micafungin 10 mg/kg. Tissue culture from atrial vegetation grew candida albicans. Ba was diagnosed with Fungal endocarditis and advised to continue IV Micafungin for 21 days along with Fluconazole. Repeat ECHO done showed no residual mass.

Discussion: 
Introduction: Fungal endocarditis in infants is a rare but serious condition characterized infection of the heart’s inner lining, particularly affecting the heart valves, due to fungal organisms. This condition can occur in newborns and young infants, often in specific clinical contexts.
Risk Factors
Infants may be at increased risk for fungal endocarditis due to:
• Prematurity: Premature infants have underdeveloped immune systems.
• Low birth weight: Weakened immune defensescan predispose them to infections.
• Central venous catheters: These can introduce fungi into the bloodstream.
• Underlying health conditions: Such as congenital heart defects or immunocompromised states.
Common Fungi
The most commonly implicated fungi in endocarditis are:
• Candida species: Particularly Candida albicans.
• Aspergillus species: Less common but still significant.
Symptoms
Symptoms of fungal endocarditis in infants may be nonspecific and can include:
• Fever and irritability
• Poor feeding or feeding intolerance
• Lethargy or decreased activity
• Signs of heart failure, such as respiratory distress or cyanosis
• Presence of heart murmurs
Diagnosis
Diagnosis involves a combination of:
• Blood cultures: To identify the specific fungal organism.
• Echocardiography: To visualize vegetations or damage to heart valves.
• Imaging studies: To check for embolic events in other organs.
Treatment
Treatment typically consists of:
• Antifungal therapy: Long courses of intravenous antifungals are often necessary, tailored to the specific organism.
• Surgical intervention: In cases of severe valve damage or ineffective medical therapy, surgical repair or replacement of affected valves may be required.
Prognosis
The prognosis for fungal endocarditis in infants can be guarded, as it often depends on the timing of diagnosis and the effectiveness of treatment. Early intervention is crucial for improving outcomes. Overall, fungal endocarditis is a medical emergency requiring prompt recognition and comprehensive management to reduce the risk of serious complications.