Fungal endocarditis in a patient with acute leukaemia treated by valve replacement.

A 32-year-old West Indian woman with acute lympho? blastic leukaemia received induction chemotherapy with doxorubicin, vincristine, prednisolone, and asparaginase. Ten weeks after the diagnosis had been made, while in remission, she suddenly became short of breath. The haemoglobin concentra? tion had fallen to 7-8 g/dl from 12 g/dl over seven days. On examination by auscultation new murmurs of mitral and aortic r?gurgitation were heard. Over 24 hours her blood pressure fell from 120/80 mm Hg to 85/55 mm Hg, and there were signs of congestive cardiac failure with basal crepitations, a jugular venous pressure of 3 cm, and pulmonary oedema on the chest x-ray film. The sudden loss of her right radial pulse and recurrent transient ischaemic attacks suggested systemic embo lisation. A two-dimensional echocardiogram (figure) showed a large vegetation on the aortic valve and small vegetations on the mitral valve. Left ventricular function was not obviously impaired. Candida guilliermondi was isolated from blood cultures. Because of her clinical deterioration and the echocardiographic findings, the aortic and mitral valves were replaced without further investigation. The aortic valve had been destroyed by a large fungal vegetation, which had also eroded the anterior cusp of the mitral valve. The aortic and mitral valves were replaced with heterografts, though it was difficult to anchor the sutures through the friable and oedematous cardiac muscle. After 12 hours of inotropic support with dopamine she made Acute leukaemia is not a contraindication to major cardiac surgery