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slql JO Xuaua5r1]luo 1r1o-i1o'palsaiiSns oltr'rJua',\ 1q"sr'r aq1 3:o uor5or o111 tll ss'rrrllng -1tt'Ill.rlru aq1 Jo ilorltrU rrlTJ rltr,\! lIl3luo5.llrluar .ltllnJI.Illrar J IsI Irul? l'ur.1J1l JId{ f aI.Illrll IJlra^i}.r

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_o.rJralo aqJ.SJilllrI l,t?l[.rou urll]rr\ a.raj-!\ IIO1sslulfl? IIO S]SO1 i.IlSlruallt pooltl lrllt'lrrrru,' lroolrl

a+rrli\ rltJtoJll1tratl .ulqo15ortrorl orrrlrloU'p.rro1l o.ril,\\ i:iullrlrgnsur crl.Ioll Irrtr'srsotlals tl1.ro?

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puoras cr?.ro]t arl:l 1r!111. Jo|tloI s"-[ L]lrnos i)uor;,s i111g1,trt1nc1 orTl. +.I1l.rr[ ,i11:] oJ IlaluuTI o.ia.[

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11t urr51] pult 6 Jo a.ic :Iil }u .rJrJI ,r1TlunJrl.r fltrl ii^l]Il oJ ua\ou\ sll.\\ JII 'asrJs-lp .lrllrhlllrcTJlunallr a.lil.\a-s Jo alsnt:la{l s.tte-{ Ia 1o oSlr ar11 }t}'096I'6a'cte,{ uo 1tl1rt{sog 1sr1cl'eg turio.IllJ

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o.rJ.\\ asarl+ Jo lsolf 'oJnlure lll ar{} irr sr}rll.ru'roPrr.r Jr}o)-iru Jo sosllc tS,iluo puuo] olqB sp/\\ r8c6[ ur cr']rllltlJ,ral['Pa]oodsilsrln -il]uanl'J,IJ J.lts puP (osou.Strp 0]

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Vol. 48, No. 4October, 196-l

ASP-ERGII,LUS ENDOCARDITIS 653l1'

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Er- ,.''-'.*"**,-**;;*&"!'ig. 1.-This preopefiiti\:e roentgenogram rlenonstrates total carcliomegaly with left ventricle

and Iight atrium contiibLrting to the enlerrgecl carcliac silhouette

ch:lrnber a,lso. There was pa,ssive congestioll of both lorver 1ungs. Carcliilc c:ltheterizatioll \\'tts

lelforlted which rcverllecl elevu,tiorr of the pressures in the right ventricle, the right ma,in

puhiron.;lr1'[rtr.ry, tlnd l]re pulmonary $,edge. Thele was no eviclence o:f abnollr]al shuntirrg

of ltloor,l. r\nal"vsis of the ptessure (--ulves taken clurlng the course of c&theterization sr:ggestecl

rh&t tlic prinra,ry lesion rvas rnitr.rl stenosis l'ith minirna,I mitral insufhciency. No evidence ofaortic stenosis or ilsufficierrcy- could be clemonstratecl at tliis time, clespite murmllrs suggestive

of tliesc lcsions.It rvtrs cle cicletl that closecl mitrtr,l valvulotomy shoulcl be pelforniecl. This operation

tooli place on llarr:li 10, 1960. 'I'he mitral va,lve olifice lvas estimated to be 2.5 sq. cm. insize anil lr,as openecl b;'finger fracture along the anteriol comrnissure to an estitrated 3.5

sq. cm. Tlie valve $'as calcified, quite rigiil, and the chorclae tenclineae lvere sholtened and

fused. I{ilimtrl mitral insu{liciency lvas thought to be increased slightlv by tire surgical

treatrnent. Thlills of aortic regulgita,tiorr and stenosjs were p&lpa,ble dulilrg operation' There

wcl.e no postopr:r'trtive complications and tire patient l'as tlischargecl on the tetth il:r,y inapparent goocl condition.

ytr,mission No. 9.-The pa,tient rvas leailmitteci on NI:r,y 27, 1963, after being fol1ol'ecl

at frequent inter.vals in the clrdia,c clirric. His con.lition h:lcl been imploveil consiclera,bly bytire opertrtiol a1d he rvas ilble to leturn to lvor'li, being mtlinta,inecl ot a lorv salt cliet, cligitalistarrcl pelicillin. He clevelopecl atritrl fibrillation a, few rveeks beforc a,clmission and again began

hrving cli:fficulty lvith episoclcs of tlyspnea ancl chest pain. IIis history also suggested a recentepisotlc of pulnonar';r enrbolism. Blood pressure on aclmissiol rv*s 124/5'1 mrn. l{g, pulse lvas

?2 pel milute ancl il.r'egultu. There s.as a loucl rnurmur of mitral insufficiency, tulr:l a faintmurmur of rnitla.l stenosis. Nlurlturs of aoltic stenosi-* tlrrd insufficiency \1:ere sti11 present'The chest x-ray stuclv reveale.l an enlalgecl r:trlcliac silhouette (Iig. 1). Thele la-s passivel.rypercmir of both lung {ielcls ancl sma11 l-iilatertrl pleural effusions. A cilre-tngiocarcliogrtr,m

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,paUodor s",!! tlJa\or5 ou prn? parrrrlqo o.rar!\ urrFe sa.rnllnr lroolg'l)iu,rn+a.i dllt;Itprl.l8 aslncl

IlrJqll rol.ralsocl 1;al aIIl pol.Iad .InoI[ 8f 1] .Ia.LO apls lJaI ariJ uo d.IaJ.It lllroluaI orl? ^\olaq ]laJ

oq pinor soslncl oN lnlur?cl puu rparltul?iq'p1ol arutaocl 3e1 .ro,lro1 lIaI orll'11 d1n1 n6'aposrda srql 3ur^\oIIoJ sdep 8 .'(i6?tlurro.rdclt .roJ alr.iqoJ acl o]

llilnurJtrot oI{ 'uoll1rzTI1?ICLqOrl Srrl IO .re prrr?uTa.r 6rll SurJnp pourllJrrrlru a.ra.{\ s[J.\dI ,r1lrodt.lJll]

put ua-\r5 st^\ runtpos ur.rlll.rtl,\\'ar1,:l arlaqlso.rd 3II1 uorJ snloclrua u€ Sutrcl str1l lo pooll

-1lo{r1 a1[+ Io.\\of^ uI'.Ialau?rp urluJ I ".eurlns1]atu'pesrl:}.r prrt parappa.r i1rq.3r1s 3{t o} ptno}sr?.{\ s[[J l)urll ]J;rI arll fo uIBCI all] ur lods .roprlo] 1l padoiJ^a! +uarJ€cl a\+ '1 .{lnl' Tro

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unlndS 'qlsorF l?rralarq JoJ erTlrSau a.ral erxal-iid Jo lt:^.raJur srIlJ oerrr.rnp parlr?Jclo sa.rnJlnc

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sr-\! aT{ 'rrrJacduro.iolllc oJ J^r]rsrr3s t1'1or1 's,t'u,:taotao .D+cD(lo.L1F put ?lo, nl\?x.tarps! palBaL-aJ sa.rnllnr ourrlf uorlll.rodo orll JalJu srlaa,\! %a.loJ aur.[J],ilsnonurluoc s1l^\ aI{'irrlluruadprrr 'url,truolda.rJs rsrplrSrp 'aurprrrrnb 'slrrt,rolladxo t11r,t llo,rrlt.tadolsod pclr:a.r1 sr.-.u trrerlurlor[[ 'urur^rlcl ]o Jrrrn airo pr? poolrt alorl.u ;o 'a'r gi;q(3 Jo Ira+srsrro;r xrrauraotlclag padolarapI]trorllotrIorl p1111 IunrlJ.rllrr.radotuarl 3l{l1l.ra!rsuoJ lnq s.ialalll13c lsorlt arll rl.Sno.rrl+ l)aJTnt€^aslla lloolcl srrll Jo lsoIN'pol.rad inoll 8r ?s.rg alll "5ur.rnp

al'ecls 1t.rna1d x1o1 arll olrr 5urpaa11

panulJrr0r oruos aJrdsall alqrls fl.n1?J lldlr1llrrr3.r rrorlrpuot atllt.raalolsod aJrrLrJrrrTur s, ltarJ",IsllJJ 't?lsarlJsau! .ldpIIII st?^\ arl oIill.\\ Xno paJI.I.Illl s^tN uoIJ'tlIIl.Ir:lgAp IBI.I]11 lua.I.Il1t Jla.ll(I',irlruwrp Jnorilri\ i^n1nurrtl lu.rllur all:l oltn pil,rlllns sr.^\ i-rsdrl+srr,rd sLi.rH\\lrf[-J.r€r]S \' paltasels?,\\ arlTr It.rJrru ar[] '-'std.{c1 i,rttotulnclorp.r?, rjenr.rnLr pn'tl t urolo'.it.rolll lIaI tr rliino.rrl]

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-a.r o.r.l?,r p.rlrru oIClri(lo.rcl ro; palnparlils slrN luarlecI e11;, 'luaso.rcI st,rt. dorraraurnsuuTJ.1or? Joaa,r5.tp lrruruiur fi-'olrr,rluoA frir runr.rJt llal aql q?oq Jo uorJr?llrlrp cl(lr.roplsuoc s1l^\ a.rarlJ'a,\i11.! It.rlrru arl] Jo IorJc.)U:rJlrJ L]arl.r1?Tn rllr,\\.,(rrr0Ttrlnsur prrB srsoliaJs lll.rlrrrr aJa^0s palTa^a.r

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OcLol'er, l9o-lA SPER GILLUS INIJO C]ARDIT].q 655

H{,,#l;:"il.i",-:1,";lil;f.tk*';:ii#i$:i4i'""%ffltf,H:i,"".1,,.r.Hq3}.$.:i:"t*j;fi];: ,#;.Xf;"^';iiit;;i: ?i:;"il,i&l,&.i,i",,i""..L*T,i,,".i"r:ru:*;,"":"j;;tiri'Bi,;;" ;li"-l;iii;

I)uring the last 2 l'ceks of hospitalization the patient inproved consiclerzrbly. IIis chest cleareclof retained blciorl, vital capacity imploveri, ancl he felt stl.onger. He rvas cliscirargecl o1 gretortieth postoper:r,tive clay to continue on \\iarfalin soclium. No other. emSolic episocles h1docculled over tire prececlirrg ? rr.eelis.

;ldmissi'on iYo. l.-The patient r,vas rea.rlrnitterl Aug. 29, 196:1, because of rlnrerouspetecliiae rvhich lirst appearetl 20 rltrys pleviously. Initiallv he l.as trLhnittetl to his loctrl

::-:p:t"t because of the possibiiity of excessive tnticoagultlnt thc'rapy, anrl rv:rs given peniciilinror temperature elevatiou. On aclmission to the North Carolina Baptist llospittr,l, tire blooclpressure rvas 110/70 rnm. I{g. Thele lere runrerous small petechia", rr",aro.rng I to 2 nrrn-,over the shin and nlucous ttremltrarres of tlie entile borlv. The prosthetic nritr.a,l ltrh'e seemeii

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dsdolne aq+ Jo ratlurllrud.r allI '(t '5lu) snqruo.tll+ I?rprl]toljua eriJ Jo snollaas ardoaso.rc[u ar11 ur

pa!:rluopr a;ra,r ar:qcldq snllr5.radsy sno.rrrunN 's1r'ln0xul11! snTLx[].LadsY.IoJ a^I]Isod oraa lll€6p o]

io-.rd p".,.e1qo so.Inllnt poolq lnq 'r.Eun; pue trroJ'eq rlloq ro; orrle5au o'ra^! poolct Funl pue

lr..aq arl+ Jo sa.rn+Irir uoq.rorulsod ']uarr!+nsul dlpuorlcun; ruar11 Surltru (p tg '5rg) sclsnc

crtrro; olll q5no.rql cln papn.rlorcl snqruo.rql orl+ Jo .ran5uoJ), Y '(g. put 1- 'g '5rg) el1'uL

cr1a.11so"cl aq1 ;o SuL.r.bur',tas uogaS ar{1 }o oprs rtlncrrlua^ €rI} uror} SurlturFuo snquorrl+

parr.,u$-ro a$J€l r st.t! a.ralil 6.{{l?r! cIJIol; aLll o} luarttpY'uaalds pu€ r.Io^rl's8un1 aril Jo uorlscoq

-oo, *1ro, areq;,'srue.r8 g,cg paq8Le,lt 1.r"arl orll [orJl]uruexa rua].rour?sod 11:-'lisdoTtlV'pour€+qo se^r lsdolnt: uY 'ra+€I srnoll 8I palp aq pue lloltror.rolap dlprdtr uol?lpuo' srH

,a,l.suoclser.,n autrroq prr€ 'o,rnzras lt;ru purr5 t pr:q 'nr5aldrurorl poprs-l}al e padola.r.ap lualludaql rgg6l ,I .lclos rro '.rotl]I sdrp lB.ra^as II+un palrodar lorl €ra.\! 1nc1 palsanbe.r are.\t sarpnls

sn3und .surs[rrr3.ro 11]rrolrTtC{ JoJ o.{r1€5au o.ra,r! rlJrq,\t Jo IIts uorssrurp€ s}rll Fur.flrp unt:p .rrcn

Barn+lnc poolq 6I Jo LElol y 'ripocl arl? Jo acelrns 6rlx uo rtads slrutsnoql d11t'ra1r1 6ra'\{' erarll pul?

dlprdr.r pas?iiJcul a'urrlcalad 3.o raclrunu arlJ. srnoq la lxau dq+ SurJnC[ dr.[,"p"or{ o'ra't'os € pu€

nrBd lrururopal€ ltodolo.\ap i]T{ 'azrs ur .urIu q o1 dn parns?3rtr qcrqa }o aruos 'saStr1,r.rourar1

I1}rqlatracl ;o c1no.rF rarlJotrll podolalap luerJl:d all? s rnorl 8i raUY 'a-u tr,-8ou ocP 1r'l-!r

trolssrulpl| su[] ]o s,rnor[.\\aI Ir:rJtur aq1 .tiurlnp pouTrlclo sarn?ina] pool.l xrs put: a.rt1r:5atr IITI d.Ia^1

lelrdsoq .3ur.r.re3.0.r arll uio.rJ palrodar sarnllno poolg '(g prr€ F ra '3rg) snrlg e^1+ll.radoarrI

rlJr,( pcJ"c1uoc e zrs ltrp.rct ur oslla.rtap alqtJaprsuoc p0lllcra.r sruig lsarlC Io.rluoa I€urousoutrl Iirrl,auo pull 0{+ s?,rr orul] urc1uo.n11o.rd orl; 'llrruJorr Ilts oJo^r ss1.{1o11ra1o runres

orlJr .sJrrurl l€ru.rou ulrlJrr\ aslt\.IarlJo sl].\{. Jnq slsr:'l .relnut.r5 pe,\\orls srsdl:ur.rn allll 'It}u.Iou

e.To.{\ Junoo poolq a:}rr[^\ pur: urqol5ourorl arll .uaas 3Ja,\\ so(:tstl]rornoq .ro1ur1ds oN 'sJo+ pull

sdrlla3ug aql ur punoJ arat\ sapou srJalso .tor:l€urur"xa Snorro.rrl all? uo trlJ"arl uaaq p?rl u€rll

Jopnol rilq?.roplsuor se.\\ sR1;, 'dcuercgrnsrfl ct?.ro1] o] inlr ac{ o1 1q3nor11 .rop.roq I€IIJOJS UaIar11 51O1r: JnurJnrr rrlols"rp pnol

" su,\t 8,rarl[ 'uorl€llncsne dc1 .,{11'eur:ou SrrrloTlrunJ aq o+

( Fy'r lr3f,npa.r : 0qtX ) a?qd.{t{ -SuILiJut-.rq al"}d:s a}oN uo-r1

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October, l96-l.\ r:PlrR (iILLtrS IiN DOCARI)ITIS 657

ralte it \vr's thouglil that the crttlrolirr episo.les rvhich tlris lratient eriperielrcecl shortll- aftersurgerv rvi:rt'norlsoptio in rlttture. Ife iras tr{)ate(1 a,r(rofdingiv u.ith anticoagulirlts. I1 ri:t;o-spe(tt, thil ser:orrrl etnLolus rvhir:h $-:1s large eitolglL t6 o|struct tire pripliteal alterv rnight |aveLeen the (tlue to th(r r:ou.ect diagnosis.r. e, 1a

DISOUSSION

Specics of thc genus Aspci'gillus ilre yer'\: coullnorr in the gerreral en\ri1.on-llle nt; iil)pl'oxitllilt(lir ,j50 hale bcen iclentifiecl. Thcr- inhabit the soil abuniliurtlyillld a1'e fc'ult1 flecluerltl)' in celeal ploclncts, gr,ains, seecls, hal', stocii fcecls, 2nc1llour'. rntelestinglr-, the patient r.el)or,tecl here rvas enlplo].ecl b1, a balier,l-, al-thoLl-q'h no specific soLtlce of fungal contaminatiorl or eviclence of bodill. int'es-tatitln of .\spergillus -"r'as linolvtt. Aspelgillus spor.es u.r,e \vell suitecl to atlros-Pilcf ic clisseminiLtirtrr. Thcr- ilI'e con)rl1or1 lrrbor.ator.l. corltarninants ancl ]rave beenlabeleri "weccls of the cuLture r'oorlt.,,ir

The organisrn l)elolrgs to the firrniJlr !.r_rn-ei hnperfecti. trlorpholo-qicrrll1,. ithas brariching septate h"vphae rvhich occasionalll- {olrir foot cells in vir-o.r' The]n)-celial glowth is charrrttterizecl by' nLlnrerous spore-bearing iLearls ctrllecl co-nic-liophores. The nrolrl pro:Jpcr.s llrl(.[er a variet]' of cilclnstanccs. rt gi,owseasill- oII food stulfs tttttl cottnronlv crruses breacl ancl nreat slroilagc. It growsbcst at 37o (,l..but hns been deuronstratecl to si_u,r,ive belou,0o C. The spor.esirre thicli walle(l ancl lesistnnt to clesiccation. Some species inhibit the grorvtliof hactt'l'ia. I-Litvir'in. irn antihiotic rvith characteristics sinrilirr.to lrc.nicillin,is clt:r'ivet1 from l sti'ain of .lsytergiLLu,s fltLu-us. Thele is sorne sinrilai:it1- to glncliclabut tjle largcr h;'phite anc-l gleater tenclcncy to l:rteral br.anchine character.ize,\spo'eiiltrs.

The genrts,\spelgillus h:rs been l<norvn to be pathosenic to ryilcl iurri c1o-mcsticatec-l attinlrtls, particularh- birils ancl cilttle; ltut rrrost spccics ai,e gerrer.lllvconsiderccl nonpatirogenir: to utan. .lsper i;i!!,tts f tr,niyafus has been shorvu tohlvc it lorv olclel of infcctivity in hrunrrns uircler or,clinar.v circlrirstllcgs, blttntrl'lreconre rluite virulent in cases of altered liost resistanc:e. Asy:tergilLtr,s niger,'1s'1terl1ilhts g1l.cttt't:tts, and )sperlliLhts flun;tts mav also trndc.r sonre cir.cunrstirilreshe pathogenic. Thesc ancl otlter irlirnarily saprophl'tic funsi have beel terrlecl"opportunistic" pathogens.r0 Thev are usualll' reporteclr: as ter,minal infectiousagents in persoris sulfering flotn sevele rvasting cliseases, often neopl:rstic i1natnle. Tire role ot' a,ntibiotics in fnvoring gro."rrth of resistant orglnisrns of lorvpathogenieit]' is rvell knol'n. This lolv pathogenicit-y nriry ciransc c'h.irrnaticirlll,lvhetr tlleir numbel's are increitsecl by- suppression of the other flora. Ovegr-1eh1-ing infections ma)- follorv if liost resistance is reclucecl br- l,asting tliseast-. or.lrntlsllal cilcurnstances of r,vhich carcliac srlngery rnav be one example.':

In 1955, Zimmermanl? ennrnerateil thrce basic f:.rctors rvhich he beiieveciwere important in preclisposing the inclivit-hral to any fulrgal ilfection: (1)dcbilitating disease, especiall;,- leuliemia ancl 11,m11[emris, (2; n ]ocrrlizecl bleal<in the sliin or rllrlcous membrane provicling a portal of entr;.. for frurg.us, a1d(3) disturbanccs in t)re saploph].te-host relationship ploducecl bv dl1gs slchas anticancel chemothelapeutic agerrts, steroicls, and nrrtibiotics. The liostflecllrent human infection clue to Aspelgillus is e,xternrrl otolrr-cosis.3 llcr,e the I liii',',]r.:

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,;r1ip"orop,,a D-niirrnr fo scsrJ tll lo -{\arAOJ }uollaJxo s^1{ ur el}ur?rlo.ral{'p?})ad-slls st lr Jt -illlo Jllrlrr "r(l urr.r .illtllsll stll[,.] lrJol'tld ,,tlo.,-ilu .l o slsoll;lrl[r JllJ

'-i,roS;rns 1J1?01{-1I3do st ssa'rJs aJJ.\Js lllns i-ul

-,rolloJ,iia>1r1 a.rout -ilclt,roprsiiot uollJaJur Il?JIlIIic ts o)laLu plnoqs s[11Li,r'tdsy;o

o,rnlgu crlsrulq.roddo or{;1,'l]o,1ol-)rsrroJ aq lsnru uoll.Iasur s]r SrIrJnp Jo o] 'rolJda.LIr.r Jrlerilso.rti ar1] fo uoiJuurur?luot ro,\]IIlqrssod aq1 o"raq pJl,lod.r,r c,str.r Jl{J

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urr i:i1ua +o spl.tod alc{Issod Jo rt}atJe.\ 1? o} J[ar^]I spual ,ira5Jns tBlP,rlra)

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aqJ 'aruB.rluo Jo 0lrs al{} sr? sLrorJJcIrrr snouol].r]ur lJo.rrp poluatlo.r 5rn1sa..iSus(r-],lrppe uroJerl uI sIlIprLlJolll{J Il?IlluoIIr 1o slstrJ g 1ra1.rotla'r at6I lII qi.ral{l^\l'a.ulrpr,rerls,iJuo sr ruals-is .{.roleinc.rrr aq1 olul r5unf ro -i.r1rra.1o 1t1.tod ct1;,

'suorlBlr-olrusru uuclo.rd osorll sould-tl PO].rocla.r

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aruos lrl ',\(uoltalstul lEJIpt.I u Er-tt,uo11o1 llollDoJul puno,\\ sn11rF.r,r,ls1-- yralnrutl

]0 os-uJ lnnsnlrn ut pauo(la.r "sor1.:in11 |rup lloJls^l?fl':ltt,r1 ItIrIlsalIIIorlsr'; pun

'pur.St.!'ttr>1o^'Sttpotr rldur-t1 'r^o8tuout'SOuO<1 'Slttu arl] uaaq a,\ul{ snlir,i;ra,Is1- o1

onp ilpouoda,r liorJlarrrr ^,rrturrrd

pozrlrDol 10 salis .ioq]O 'saJods sr-r1it,3,ratls1' 1o

notJlrlurltll o] patrn(ll,IUl? uao(l Olllq ao'r+ I?IrirIIoJqocqot.Il alll Jo b-uotlrl)un'r )tF

-.rall\i ,'ruiiul11Ll.rd .(q pa1.rotlo.r slllllrlltl.re d sn11l.3;eds1" lo o>^l?J aql rq palu,rlr-il{[r

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oJur uorb-uolxc 1)c,rr(I'solonlJuoJq.ro sJlrjr,rrt lt.tatlth.rJtI ttr sor-SeJr-{[B lJ1?tus

5rnur.ro1 r11r5.racIsy SIIIJ.\O.I SOIrlIlOtuor- -isdo,t. crt 's,r,rtp .rO.1 pun(1I.IOuI IIcJq !)-\l:lII011-\r sluorlt?d po1u111rqop,i1c.ro-las uI's.I;)tlso.Itll puE's,ia-.1.ro-rl 1lrrtr-1sr.r.i's,1-rtLt'lr-.Iol ll,ltlzur{ luuor:]"dnJ)o ul? sE pa]Drllrrr uaarL oslrt b-tlq.;uu1 ar1] lo lrialllc-llo.\1IT')-lsoIft,oq.radst] -i.rtttcittrptl padolc.rop oq,t aa-iolrlura p,It-i)[Jo]s l,' l.rlr.ll:,\\t-' irtr.rr 1

uorlusltadrtto) S,JJ{.Ioi! lo ellol.IOdaJ sPI\ ob^l?J Y 'p,lEZIrl 1ttrot1erI1.r.rO tlll l}'r'T'lpI{-r1o,) lra,\o Pui? pol.rodJ.r uaa({ srlq lilq uolllttlo) ssal sI uol+,)')fiu -i.I?iIII.r.r r';'Osl?aslp

srrll To ur.toT Iultslt ;lll] sr SrsoIrlo,Iaqnl ,lo(SIslr],).,It[')tlt).Iqrssrr\rlIl Il?I,ra]JBq rllIo'tIIJparisliqs]>^e -\1sltor.\crcl u ur SrrnI aq] Jo JIIcruo.\lo.\IrI -\.rlrlluoJOS',r,rlrta lo olno.r

I?lisn atll sr so.tods.ro prla).iur 0r1l ]o iiorltIllqtlT'slu,Ior pazIlt?Dol lIr,,rf0puatu-rrroJ;.r I;1:nsn sr rrorlJosJt['rLls]rnrfi.ro srrl] 1rlo.r] 5ttr1pr.^a.r cstoslp a.ttst'-rrtt -ltL,,itlr

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stlggestive of errcloctrrclitis if there is n significant heart nlrlmruf ilrrcl e\.iclerleL.of rntrjor crnboli. aIId (2) in the patient $'ith appirrent sriJ)acute ltacterial enclo-cilrclitis in rvhotn I'outine Jrloocl cultules arcr stelile. Several irutllorsl'e rl h'1\'erloted that the lalge size oii m1'cotic veqetations possil)lJ- accolutt for the ile-(luellcl: of crubolisnL to lar-ge arteries. This manifestation of fungus ellclocarclitisis lepeatecllv ernpltasizccl as an irnpoltant clinicirl clilferentiation from bacteriaiclldoctrrditis. l'lre sizc oi the vegetation in the crrse lepoltecl can be reaclill-apJrlecizrtecl in thr: photoglaphs (see !'ig. :3). Othel clistinctions betrveen m]-coticanc.l ltactr-'r'itrl enclor:arrlitlitis ale tlifticult to nialie on clinic:rl grorlncls alone, as

the trvo closell- mi'- ic each other. Ii'ever, chills, anorexiir, nausea, r.orniting,heyratosltlenottregalr-, pctechiae, splintel hemor^r'htrges, f)sler"s nocles, leuliocl'tosis,elevittion of the serlinrent:rtiorr rilte, lrcnrttru'iu, itncl pi'oteinLuiil are ciolnlrlorl toboth cliseuses.

Tirct'alreutic nleilsuT'es htrr-e not ltecn satisftctor'.v in the controL of svstetricfL.Lngus inlectiotrs.s Ioc,licles 5i1',.1. provecl o1l orilv rnoclerate valne." AmphotericinB ]ras becn usefrrl in controiling Cirndicltr in some casctsl;r'tn J)ut cannot be con-sit'lt-'recl 11epeni1ab1e. It has been shorvn to retluce thc. colonr- count trnd teurpo-lrrrilr- cleal the bloocl strean] of organisrns Lrut r.vith lare e\ccptions h;rs not Jlecn

clu'irtiye.1 Peer'1; used this clrug lvitir goocl lesults in one case of irspelgiliosisof tlic lung'. Kttl'l0;11'gelirpiished a cure of Canclic}L eldocilrclitis of t5e triclspitlr-irlvc' l.rr- surgical renror-al of the vegetation concouritantlr- rvith ciosure of itr-entlicular septal (.lefect rvith the use of open-healt techniclrLe. Nl-stal.in r'r.hich

is effective against f]anciitla is availzrblt-' for oral anrl topical use Jrnt is notabsorbecl florn the gilstr'ointestinal traet ancl is ineffective irr sys1e111ig infections.hrhulations of N.r'stirtin nrist hiis been beneficill in sonre c.lses of pulrnotrar'1-rLspe'rgillosis.'s (.i liseofuivin has been foLtnil inofTei,tir.e in s1-stenric lungal dis-eilscs.6 \one oll thc usual hrotrtl slrectlum antibiotic:; arc tlrctapcuticallr- eifer'-tivq iig:lirst tLrrgi: il {act sorr-re autl,;i s "i hiLver clesc.r'iitr.lc'l c'[issenrin:rtion ofprevionsll- lor:iilizctl futtgal inlectiorrs follrn ing antibiotic treatnrent. In atfu-litionto altelirtion of the norrnal sr-rnbioticr relrrtionship betrveen fungi anc'l bacteliirthere appears to be a stinrulatins effect on sonle fungi b1':rntibiotic cll'Lry,^s.

It lor.rld appcar frour pnblishecl rcports that nrl-cotic entlocarditis is in-creilsins in inciclence. If true, this rvoulcl not be stLrprising consideling theuniversal prrcscncje oli fungi, the cver increasin-g a,ee ancl clebilitv oil sorne see-

tnents of the sulgicirl j)opLllirtion, the incri'ciLsing usa-qe of antibiotics ancl colti-costeloirl c-h'uEs, ancl the lepidll' expancLing fieltl of eai'cliac sllrger'\-.

SU]I}t,\RY

Thc iucitlencc otl bacrtcrialrcporte(l to be about 1 peI cent.conplicatirrg open-lreart surgerl'Canrlidn. Tlelein is rclloltetl theA sper (tillus I unt ig ut rus. I'levioususuallv lteen "oplloltulListicr" irrperiocls of tinte t'r'orr chlotritr

elrclociu'(1itis follou'ing open-heirrt surgerf is

Recenll.r', scvc.lll cases of tiungirl enrkrtlrclitishave been leportecl. l{ost of these u-ele rlr-re tofir'st linorvn ciLse ttI this conrplic:rtion clr.re tolepolts of infcction rvith this orgianislr irave

T)0r'sorls rvho harre lteen berh'idrler.r for longrvastins c.liseirses. Difficulties iri nrakinq the

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cliagnosis alc stressed ancl the necessit)'flor obtaining ear'l.v fungal clritures iserrphirsizcrl. Dlug ther:ap.v of sl-stelnic fungus inlcctions is grossl;t inaclequateat the plesent time. Repolts in the litelature srlggest that an increasing numberof s1-steuric fungal infections rvill ]re secn in tire future iir vier'v of the ever-e\piincling field of caraliac sul'gerlr ancl the conconitarlt increasing usage ofprolongecl antibacteliaLi thelap.v.

REFERE\CES

1. -\uririaole, V. T., I{ravetz, II. }f., Robt:r'ts, W. C., tnd IJtz, J. P.: Cnntlidtl Errdocalclitis,Arn. J. X'Ierl. 32: 251, 1962.

3. Coe, G. C.: Prirnar;- Blonchopulnolary Asliergillosis. .\n Occupational Disease, Arrrr. fnt.. tr{ccl. 23: 423. 1945.

;J. Crarvlcy, E. P.: '\spergillosis trnrl tlie '\spergilli: Rcpolt of a Lrniqr.re Ctrse of the Disea,se,Arch. Irrt. Mccl. 80: '1:ll, 19+7.

4. Dcnton, C., Pappas, E. G., Llricchio. J. F., Golrlberg, lI., and Lilioff, \Y.: Bacterial Entlo-calclitis Follorving Ctrdiac Surgcr"v, Cilculation 15: 525, 1957.

5. llastcott, H. H. G.. antl }Iughes, \\r. 1-I. : Postopc.rativo \Vound lrrfection \\rith .lspergillusFurnigatus, Brit. J. Surg. 50: 6ti2, 1963.

6. tr'iregolii, S. I{., \Yill, D., a.nr1 }Iurrtrv, J. I'.: ,\spergillosis: A Revieiv ancl Report of 12Ctrses, .\nr. J. IIcd. 27: 46i:i, 1959.

7. I.ltunreni, J. F., ancl Ifea,r, R. n.: Pululer.Lt Pericl,rilitis in Aspcrgillo-sis,.\nn. Ini. IIed.57:3llt, 19(i2.

3. Ilx"un, B. II., anrl Collier, F. C., N{ycotic Eliloearditis Follo*'ing Tntrucurdiae Operatious,Ncw' Englancl ,I. ]Ied. 263: 11339, 19ii1.

9. Jarnshii.ii, A., Pope, R'. lI., u,nd 1i-rierlman, N. H.: Fungal Encloetrrditis Corrrplic:rtirgCttlrlitc Surgely, .\. I'I. A. Arch. fnt- Xlecl. 112: 370, 1963.

10. 1iay, J. lI., Belstein, S., tr'einstein, D., ilncl Biddle, NI.: Surgical Cure of Clilndicla, ^\lbictrnsIlntlocarditis \\:ith Open Heart Surgery, New Errglalt'l ,I. NIcd.26i1: 907, 1961.

11. Iiirschstein, R. L., and Sidransky, H.: N{ycoiic llnclocarclitis of the Tricuspid Yalre Dueto -\spergillus I'lavus: Ilcport of a Case, A. M. A. Arch. Path.62: 103, 1956.

1!. Iioelie, \Y. A., ancl Pastor, B. II. : Canclida Albjcans l4lclocarrlitis ;\fter -\ortic Ytllulot-orly, Nerr Englantl J. IIed. 225: 997, 1956.

13. Loulia, D.8., and Dineen, P.: Arnpliotelicin B in Tleatnrent of I)isseniintrtecl Moniliosis,J. -\. l,I. A. 174: 273, 1960.

14. Luke, J. L., Bolande, R. P., anrl Gross, S.: Generalized Aspolgillosis and Aspergillusllndocarclitis il Inf:urcy, Petlia,trics 31: 1, 1963.

1J. llerchiint, R,. J{., Louri.r,, D. 8., Geisler', P. H., Erlgecomb, J. II., ancl Utz, J. P.: Fungal' Intloerlrcliti-s: lievicr- of the Literature dirci'Report of 3 L-nscs, ,\rur. Lit.'I{r:t'I. 48:: t:. 19is.

16. Pecora, D. V., aucl Ta1i, II. W.: Puhnontrrv Resection for Localizer1 Aspcrgillosis, Nervllngland J, Nlcd. 263: 735, 1960.

17. Peer', E. T.: Case of Aspergillosis'Ireated Witir.AmpLotelicir "B,') Dis. Cliest 38: 233,19d0.

18. Proclinorv, J. J.: Trea,tment of Opportunistic Fungus Infections, Lab. fnvest.11: 1917,19ri:.

19. Sanger, P. \\r., Taylor, F. H., Robicsek, Ir., Germuth, F., .Senter.fit, L., ancl 1{r:Kinnon, G.:Cnnclicla fnfectiol as a, Complication of llea,rt Surgery, J.A.NI..\. 181: 88, 1962.

!0. Seabury, J. IL, ancl Samuels, Nf.: The Pathogenetic Spectrurn of Aspergillosis, Arn. J.Clin. Path. 40: 21, 1963.

21. Smitir, R. T., alr.l Contnt, N.-F.: Zinsser's Textbook of Bacteriolog]-, ed. 10, New yorli,1.1)52, Appleton-Centuly-Crofts, Tnc., p. 939.

??.9Y, J. P.: Tlrc Spectrum of Opporturristic Tungus fnfections, Lab. Invest. 11: 1013, 196?.23. \\rairner, H. \V., Heppe.:_N: t.-G.,4"49r-*9", II. A., and \Yeecl, L. -\.: Pulmonu'y -\sper-

glllosis, -{nn. fnt. }Ied. 58: 472, 1963.2f . \\relsh, 11,. A., antl Burchness, J. lI.: Aspergillus Entlocarditis, Myoctrrdiiis trncl Lung

Abscess: Report of a Ca-*e, Am. J. Clin. Path.25: 7.92, 1t155.25. Wikler', -\., Willirms, n. G., Douglass, E. D., ancl Ernmons, C. W.: llycotio Endocarclitis,

i J. -\. l,I. A. 119: 33:1, 19'12.Zirnmerrnan, L. E.: Canrlitla trncl Aspereillus Endocarrlitis \Yitjr Comments on thc Role

o{ Antibiotics jn l)issemination of Furrgus Disease, Arch. Prtir.50: 591, 1950.Zimmerman, L. E.: I'atal Fungus Infections Complicrting Othcr Diseases, Am. J. Cli1.

Patlr. 25: 46, 19J5.

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