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A 19-year-old woman underwent heart-lung transplantation for obstructive bronchiolitis. Eleven days later mycotic rupture of the ascending aorta occurred. Emergency cardiopulmonary bypass was instituted via the femoral vessels and the chest was reopened under cardiac massage. Perforation of the aorta at the site of insertion of the cardioplegic cannula in the donor aorta was seen. Under circulatory arrest the infected area was excised, a pericardial patch plasty was performed, and the region was covered with a muscle flap. Postoperatively, Candida albicans was found in the excised specimen of the aorta, in drainage fluid, and in the bronchoalveolar lavage. High doses of antimycotics were administered intravenously and for irrigation of the mediastinum, which resulted in an eradication of fungi in all cultures 7 days later. Six weeks after reoperation the patient was discharged home, and she remains well 9 months postoperatively.

The article discusses three patients with an intraocular Candida albicans-infection. Vitrectomy was performed on two patients in whom the infection occurred after abdominal surgery. Both had significant corpus vitreum involvement. One of these patients regained good visual acuity, while in the other patient preretinal proliferation caused permanently reduced vision. The third patient had only chorioretinal involvement. After intracranial surgery for acusticus neurinoma his general condition deteriorated and he developed septicemia. He was treated with intravenous amphotericin B and visual acuity returned to normal. Early diagnosis and treatment are important for satisfactorily preservation of vision. Therefore patients in risk groups with ocular complaints should be referred immediately to an ophthalmologist. Early diagnostic and therapeutic vitrectomy should be considered for all patients with suspected vitreous involvement.

Objective: to assess the experience of both departments in the surgical therapy of infective endocarditis--indications and results., Design: retrospective analysis on clinical data, surgery and follow up., Setting: patients (pts) studied in the Cardiology Department and Cardiothoracic Surgery Department of the Santa Marta Hospital in Lisbon., Patients and Interventions: sequential sample of 28 patients (11 females, 17 males, mean age 39 years) submitted to surgery between 1978 and 1987 for infective endocarditis., Measurements and Results: the indications for surgery were: heart failure (15 pts), "resistant" infection (8 pts), emboli (4 pts) and "large" vegetations shown by echocardiography (2 pts). Surgical mortality -27.5%. Four patients developed periprosthetic leaks. There was an improvement in functional class of the survivals., Conclusion: the indications for surgery were heart failure, "resistant" infection, emboli and "large" vegetations. There was a high surgical mortality, namely in the patients with resistant infection, severe heart failure and periprosthetic leaks. In the follow up there was a net improvement of functional class. The morbidity is due to the periprosthetic leaks, which induced most of the reoperations.

An AIDS patient with a subdural empyema as a complication of candida sinusitis is presented. Clinical features resembled those of invasive aspergillosis or phycomycosis. Microbiological diagnosis was established by blood cultures, sinus cultures, and histopathological examination. An aggressive surgical approach first to the sinuses and then to the subdural space, together with fluconazole produced a satisfactory result.

Eight consecutive cases of culture-proven endogenous Candida endophthalmitis (ECE) were managed between 1980 and 1988. All patients were treated with vitrectomy and injection of intravitreal amphotericin B. Blood cultures were negative in all patients, although Candida albicans was cultured from a foot ulcer in one patient. No systemic therapy was used in three patients, three patients received oral ketoconazole, and two patients received oral flucytosine postoperatively. Intravenous amphotericin B was not used because of lack of evidence of disseminated candidiasis and the systemic toxicity associated with its use. The ECE responded favorably to treatment in all cases. Final vision was better in patients with a shorter interval between onset of symptoms and initiation of antifungal therapy. Posttreatment visual acuities were: four eyes greater than or equal to 20/50, two eyes at 20/80 to 20/200, and two eyes less than 5/200. This series showed that ECE without evidence of disseminated disease can be treated successfully with vitrectomy and intravitreal amphotericin B.

Four eyes underwent vitrectomy and epiretinal membrane dissection for tractional retinal detachment (RD) or macular pucker associated with Candida chorioretinitis. The epiretinal membranes were vascularized and, in three of four eyes, were associated with full-thickness retinal scars, presumably at the site of previous active Candida chorioretinitis. The epiretinal membranes were successfully removed in all four cases. Visual results depended on the degree of macular pathology and the presence and location of a full-thickness retinal scar.

The study makes an assessment of the results of surgical treatment of infectious endocarditis in 25 patients operated in 1982-1988 at the Institute of Experimental and Clinical Medicine. At the active stage of the disease, surgery was performed on 15 patients (60%), while prior to the operation, 16 persons' condition (64%) corresponded to the IIIrd and IVth degree of the NYHA functional classification. In infectious endocarditis, early mortality after valve replacement was 8%, late mortality--9% with an average of two-year post operative follow-up. Re-infection occurred in 12% patients, paravalvular regurgitation was found in 20 percento, out of whom 8% were haemodynamically significant and associated with the infection. Clinical post-operative improvement was observed in 76% patients, out of whom one half was totally asymptomatic and one third resumed their jobs. The results show that early surgical treatment of infectious endocarditis helps to reduce mortality. The post-operative risk of re-infection or of other complications was not high and the long-term post-operative functional effect was favourable in most patients.

Seventy-five surgically treated patients with prosthetic valve endocarditis were treated at the Stanford University Medical Center. This was a multivariate analysis analyzing both patient related factors, bacteriology, and surgical findings. The conclusions among 10 patients with allograft valves, 20% had an annular abscess; this occurred in 36% of 29 patients with porcine valves, and 65% of these with mechanical prosthesis. Though prevention, again, is key in this especially devastating disease, once infection has been established and an aggressive approach is indicated, it would appear that a homograft re-replacement or free aortic homograft valve replacement can deal with severe tissue destruction to prevent recurrence.

The clinical course of a unilateral intraocular mycosis through candida parapsilosis is described. The fungus could be histologically verified from a whitish yellow thick deposits on the lens in the anterior chamber after enucleation of the eye. The ocular infection was endogenic probably through an infested cava-catheter.

In studying the dose-related ocular toxicity of amphotericin B in vitrectomized eyes, up to 5 micrograms/0.1 ml concentration of amphotericin C was nontoxic to the ocular structure when injected in the anterior part of the vitreous cavity. Intravitreal injection of 2.5 micrograms of amphotericin B halted fungal endophthalmitis, which was experimentally induced in rabbit eyes, even after 16 days of infection. Combined treatment of vitrectomy and intravitreal injection of amphotericin B not only cured the fungal endophthalmitis but it also cleared the ocular media from opacities.

The paper reviews experience with vitrectomy in five cases of endophthalmitis in which vision was severely reduced because of vitreous opacification. In two of the cases vitrectomy was performed after the infection had been aborted, and in three of the cases vitrectomy was performed during the stage of acute endophthalmitis when there was evidence that the condition was not responding to conservative medical treatment. In all cases, vitrectomy resulted in a dramatic improvement in vision. It is suggested that vitrectomy represents a major advance in the management of bacterial and fungal endophthalmitis.

Although the techniques of M-mode and two-dimensional (2D) echocardiography (echo) have been found to be useful in patients with bacterial endocarditis, the 2D findings of fungal endocarditis are not known. In this report, we present the case of a young female narcotic addict with Candida albicans endocarditis in whom we diagnosed a large vegetation by 2D echo. Decision for surgery was made solely on the basis of the 2D-echo findings. We feel that 2D-echo findings are reliable in diagnosing fungal endocarditis because, with this technique, the size, shape, mobility, and exact location of the vegetation can be better identified than by the M-mode echo. In addition, early diagnosis of fungal endocarditis helps in treating the patients with medical and surgical therapy which may result in lower mortality.

A successfully treated case of fungal endocarditis for native aortic and mitral valves was reported. A 56-year-old male was admitted with high fever, dyspnea on exertion and oliguria. Infective endocarditis, urinary tract infection and acute renal failure were most suspected by findings of physical examination and urinalysis, but repeated blood cultures were sterile. In the course of treatment for urinary tract infection, high fever and leucocytosis recurred and then blood cultures were positive for Candida parapsilosis. Despite intensive antifungal therapy, blood cultures were consistently positive for Candida parapsilosis. Echocardiogram showed vegetation on the aortic and mitral valve. Aortic and mitral valve replacements with prosthetic heart valves were carried out on April, 1986. Cultures of the vegetation on the mitral valve revealed Candida parapsilosis. Intensive administration of antifungal drug was done postoperatively. Postoperative course was uneventful and he was discharged in excellent condition on the 84th postoperative day. During follow-up period of 1 year, the patient has been doing very well and there were no sign of recurrence of fungal infections.

A 27-year-old white man had endogenous Candida endophthalmitis with fungi in the vitreous cavity, presumably caused by hematogenous spread related to drug abuse, and was treated by pars plana vitrectomy and antifungal medications administered systemically after surgery. There was no evidence of other systemic involvement, and excision of fungi from the vitreous cavity confirmed the clinical diagnosis and determined the sensitivity of this fungus to antifungal medications. The fungus was sensitive to flucytosine (5-FC), which the patient received orally since it was less toxic to body tissues than amphotericin B. The intraocular infection cleared rapidly after vitrectomy, and visual acuity returned to 6/5 (20/15).

The presentation and course of infective endocarditis is changing because there is an increasing number of resistant organisms which are causative agents. At present, resistant organisms are isolated in more than one-half of the cases; Streptococcus viridans is found in only 40 percent. The increased use of antimicrobial agents, the frequent use of intravenous heroin and the increased amount of cardiac surgery have been important in increasing the number of resistant organisms and providing convenient access routes to the circulation.

A general review of the treatment of Candida endophthalmitis is undertaken, with particular emphasis on the efficacy of various drugs currently in use. Their absorption by the eye when given systemically is also considered. The limitations of medical treatment for this condition are discussed and the theoretical reasons for vitrectomy considered. Six cases that underwent vitrectomy are reviewed, and the indications for vitrectomy in Candida endophthalmitis are discussed. A tentative overall plan for the management of such cases is given.

Despite the large number of organ transplants performed yearly, to date there have been no reports of candidal splenic abscess. We describe here the first case of candidal splenic abscess in a renal transplant recipient treated successfully by splenectomy and amphotericin B. Despite a lengthy illness, the patient recovered with preservation of renal function.

Operative management of a patient with septic thrombosis from Candida organisms of the subclavian and central veins is described. Diagnosis was suspected on the basis of positive blood and catheter tip cultures, indium-labeled leukocyte scan, and bilateral upper extremity phlebograms. Venous thrombectomy with a Fogarty catheter of the upper extremity central veins was performed after a superior vena cava Greenfield filter had been placed to prevent pulmonary embolism. The thrombus culture was positive for Candida albicans, and the reestablishment of vein patency in conjunction with amphotericin B therapy resulted in cure. This technique allows a definitive diagnosis of septic central thrombosis to be made and reestablishment of vein patency may also enhance antibiotic therapy.

The authors report a case of cerebellar pseudotumor caused by a Candida species without evidence of any underlying systemic disorder or extracranial disease. Total removal followed by treatment with amphotericin B resulted in a favorable outcome.

From January 1980 to June 1987, a total of 16 consecutive patients underwent surgical therapy in addition to an antimicrobial regimen for prosthetic valve endocarditis at the National Taiwan University Hospital. The ages ranged from 26 to 55 years, with a mean of 40. Nine of these 16 patients (56%) were men and 7 (44%) women. The infected valve prostheses were located at the aortic position in 5 patients, at the mitral position in 6 patients and at both mitral and aortic position in 5 patients. Among the total of 21 infected valve prostheses, 19 were bioprosthetic tissue valves and only 2 were mechanical valve prostheses. Hospital death occurred in 5 patients with an early mortality rate of 31%. Among them, 1 had fungal infection, 2 had streptococcal infection, and 2 had enterococcal infection. Four patients died of low cardiac output due to extensive myocardial involvement and one patient died of uncontrollable upper gastrointestinal bleeding. Late mortality occurred in 1 patient with fungal endocarditis and the cause of death was clinical deterioration due to multiple organ failure. The follow-up period ranged from 7 to 93 months. Except for one who was lost to follow-up, all of the patients survived in good condition without any complication.

Infections are the primary cause of complications and death in patients with acute myelogenous leukemia. Current aggressive treatment protocols have improved patient survival but produce extended periods of profound neutropenia during which the patients are particularly susceptible to opportunistic infections. Candida and Aspergillus species are the most common of the fungi causing invasive infections in these patients. In a group of 77 previously untreated children with acute myelogenous leukemia begun on treatment from March 1976 to June 1984, four patients developed localized fungal infections of the lung. These initially appeared as pulmonary infiltrates on chest roentgenograms during periods of severe neutropenia (three during remission induction and one after intensive consolidation therapy). Endobronchial cultures failed to identify the infectious organism in all cases. Computerized axial tomography best defined the cavitary nature of the lesions in 2 patients. All four patients underwent surgical resection, both to establish a diagnosis (three patients) and as part of therapy. There was no operative morbidity. The organisms involved were Aspergillus (2), Torulopsis (1), and Penicillium (1). Three patients were cured of their fungal infections. The fourth patient failed to enter remission and died of a cerebral fungal abscess that developed shortly after thoracotomy. We report these cases to encourage early surgical intervention in leukemics with a localized pulmonary process consistent with a fungal infection. Resection of the primary focus obviates the risk of life threatening pulmonary hemorrhage or dissemination of the fungus and allows for early reinstitution of chemotherapy which is vital to these patients' survival.

A 39-year-old man with severe diabetes mellitus, chronic pancreatic insufficiency, intrapancreatic choledochal stricture, and secondary biliary cirrhosis developed postsurgical fungemia and large hepatic abscesses due to Torulopsis glabrata. These were treated successfully with a combination of amphotericin B and percutaneous drainage of the liver abscesses. We believe this is the first reported case of such infection due to this normally saprophytic agent.

Intracardiac fungal masses can develop following episodes of candidemia in premature infants with indwelling right atrial lines. We report the first premortem diagnosis and successful surgical removal of Candida-containing intracardiac masses in three premature infants. All had central venous lines and had been on systemic antibiotics prior to the development of candidemia. By echocardiography, two were pedunculated, solitary masses within the right atrium. Amphotericin B and 5-flucytosine for 21 to 42 days controlled the Candida sepsis, but the masses became increasingly mobile and did not decrease in size. In the third infant, large, irregular masses extended from the right atrium to the main pulmonary artery, and surgical removal was recommended 4 days after the start of antifungal therapy. In all three patients, the masses were nearly the size of the main pulmonary artery and presumably contained viable organisms. Removal was accomplished with the aid of cardiopulmonary bypass for two and inflow stasis for one infant weighing only 1,300 gm. The masses were filled with viable Candida organisms. All patients tolerated the operation well and have been followed up for 1 to 3.6 years without evidence of recurrent Candida infection. The case of a fourth infant, weighing 1,320 gm, is also reported. This infant had a bacteria-containing intra-atrial mass, which was removed successfully with the aid of inflow occlusion. This report documents the following points: (1) Echocardiography provides a noninvasive method of diagnosing the development of intracardiac masses and should be performed in infants who have had candidemia and a central venous line. (2) Prolonged systemic antifungal therapy does not appear to either sterilize or promote regression of the masses. (3) The masses can be safely removed, even in the premature infant, with either inflow stasis or cardiopulmonary bypass. (4) Surgical removal is an effective component of the treatment of infection in these infants.

Neonatal renal candidiasis is a rare complication of prematurity associated with a mortality rate of 50%. We describe a patient who was treated by nephrostomy drainage together with the removal of the fungal debris and both systemic and local antifungal therapy. The infection was eradicated and the baby survived with minimal renal morbidity. A rational plan of treatment is presented which may help to reduce the mortality rate in future.

Candida caused osteomyelitis of the spine is a rare entity. In the literature are only 15 cases reported. An own case of Candida-osteomyelitis of the spine is demonstrated and a overview of the literature is given.

Two patients with candidal sternal osteomyelitis have been successfully treated by operative debridement and adjuvant drug therapy with 5-fluorocytosine. One patient had developed postoperative candidal wound infection after sternotomy, and the other acquired candidal sternal osteomyelitis following Candida fungemia. The diagnosis, suggested by culture, was confirmed by identification of Candida pseudohyphae in debrided tissue. Histological confirmation of candidal sternal osteomyelitis indicates the need for operative debridement and specific systemic antifungal therapy. The drug 5-fluorocytosine appears to provide effective oral therapy in this situation.

Retinopexy was performed by endodiathermy coagulation around a retinal tear provoked during dissection of epiretinal membranes. The dissection was a complement to vitrectomy for Candida albicans endophthalmia. The choice of this technique was dependent on the absence of need for the laser, and allowed an internal buffering to be carried out by the use of silicone oil. Angiography showed depigmented areas confirming the presence of scar tissue as seen in experimental rabbit studies. The scar involved the whole thickness of the retina and choroid adjacent to the cauterized pigmented epithelium. This method is simple and possesses the advantage of being able to be used when the perioperative laser beam is unable to cross the transparent media of the eye.

A period of aggressive surgical treatment of early identification of fungal infection of the burn wound was compared with the previous 5 years' experience with patients suffering from fungal infection of burn wounds. The portion of those patients with Candida infections diagnosed and treated premortem increased from 48.0% to 63.6% and of patients with noncandidal infections from 40.8% to 67.0% in the more recent period. The mortality of patients with Candida infections in 1973 to 1977 was 83.3% and in 1978 was 87.5%. The mortality of noncandidal infections, 87.4% in 1973 to 1977, was 25.0% in 1978. Local surgical control of the infected portion of burn wounds is an effective way of improving the survival in noncandidal burn wound infections. Surgical excision of burn wounds does not alter the poor prognosis of patients with Candida invasion of the burn wound.

Two patients with acute leukemia were found to have candidal splenic abscesses. Both patients were in remission and had normal granulocyte counts at the time the abscesses became evident. Both patients were treated with splenectomy and antifungal therapy with a definite response. The incidence and treatment of fungal splenic abscesses in leukemia patients is discussed with emphasis on the role of splenectomy.

A 79-year-old woman developed Candida parapsilosis endophthalmitis nine weeks after an uneventful cataract extraction. The diagnosis was suspected on clinical examination and documented by culture of the vitreous biopsy obtained during vitrectomy. The endophthalmitis was treated by pars plana vitrectomy and intravitreous injection of amphotericin B and dexamethasone. The patient was also treated with systemic flucytosine, to which the operative isolate proved resistant. This was therefore immediately discontinued; however, the intraocular infection cleared rapidly after the initial vitrectomy and intravitreous injection. The patient's visual acuity ultimately returned to 20/20. The combination of these two newer methods of treatment for fungal endophthalmitis achieved a favorable outcome in a disease process that has often previously wrought disaster.

A case of a previously healthy 51-year-old man, who was diagnosed clinically as having a posterior cranial fossa tumour. At operation this proved to be an abscess which was radically removed. Histological investigations showed the presence of a fungus which was identified as Candida albicans.

Eighty-four patients with infected abdominal aortic grafts managed from 1961 through February 1985 were reviewed. Thirty-three patients had associated aortoenteric fistula formation. Twenty-eight infections (33%) and 13 aortoenteric fistulas (39%) originated at The Cleveland Clinic, yielding an incidence of aortic graft infection of 0.77% (28 of 3652 grafts) and aortoenteric fistula formation of 0.36% (13 of 3652 grafts) at this center. Staphylococcus organisms alone or in combination with other organisms were isolated from 34% of the series. Management consisted of graft removal and extra-anatomic bypass in 54 patients (64%), graft removal alone in 14 (17%) patients, partial graft removal and extra-anatomic bypass in seven (8%) patients, and miscellaneous operations in nine (11%) patients. Twenty-three patients (27%) required major amputations, nine of which were bilateral. Life-table analysis yielded 30-day and 1-year survival rates of 72% and 42%, respectively. Thirty-day survival of the aortoenteric fistula subset (49%) was less than that (86%) of the nonaortoenteric fistula subset (p = 0.003). One-year survival of patients treated since 1980 (54%) was superior to that of patients treated before 1980 (31%, p = 0.035). No difference in operative or 1-year survival was demonstrated between the group treated with extra-anatomic bypass and subsequent graft removal and another in which both procedures were performed simultaneously, although the staged group experienced substantially fewer (p = 0.04) amputations (7%) than the combined group (41%).

A case of multiple injuries including blunt rupture of the stomach is reported. It demonstrates that Candida needs to be considered as a possible cause of continued sepsis following a ruptured viscus in the presence of multiple trauma. Surgical drainage is required in this situation, in the same way that abscesses caused by more conventional organisms require aggressive surgical treatment.

Most fungal infections of the urinary tract involve the drainage structures rather than the kidney parenchyma. They usually occur in patients with diabetes or other chronic debilitating diseases and in the presence of urinary stasis. Conglomeration of fibrillar hyphae results in fungal balls which produce nonopaque filling defects in the renal pelvis, ureter, or bladder. Such fungal ball colonies were demonstrated by percutaneous (antegrade) pyelography in the upper urinary tract in two cases. A percutaneous nephrostomy was performed in one patient to provide drainage of pus in the renal pelvis.

On the basis of the data currently available, no dogmatic statements can be made about optimal therapy for Candida endocarditis. In those with valve protheses, early surgery should be carefully assessed even though the differences in outcome (17% vs 53% survival) are not yet statistically significant.

In vivo treatment of experimental Candida albicans keratitis with the excimer laser achieved sterilization on culture and histopathologically in all corneas in which clinically visible infiltration was removed with the laser at the 193-nm wavelength. Treatment at the 248-nm wavelength was not successful in eradicating infection compared with untreated controls. The 193-nm wavelength is highly effective, probably because infected tissue is totally removed by ablative photodecomposition. At the 248-nm wavelength, thermal effects become more dominant and, therefore, fungal elements are incompletely ablated. Light microscopy two days after treatment at the 193-nm wavelength showed healing of ulcerated areas, fine basophilic stippling at the epithelial-stromal interface, and undamaged underlying stroma.

This report describes the case of a patient in whom Candida albicans tricuspid valve endocarditis was treated by excision of a large vegetation and partial tricuspid valvectomy without prosthetic valve replacement. In select patients, valve-sparing debridement may allow a long-term cure and may be the procedure of choice in the treatment of Candida tricuspid valve endocarditis.