Case Presentation: A 29-year-old male presented with a 1-week history of dyspnea, cough, fever, fatigue, myalgia, and chest pain. Medical history included hepatitis C and intravenous drug use with meth, heroin, and suboxone. His last use was 1 week prior to presentation with IV suboxone. Pertinent surgical history consisted of bioprosthetic mitral valve replacement x2. Most recent replacement was 8 months prior secondary to recurrent MRSA endocarditis.Upon presentation, his temperature was 98.4, heart rate 117, blood pressure 112/78 mmHg, and respiratory rate of 20 with oxygen saturation of 100% on 2 liters. On exam, he was a thin, ill-appearing male. He had decreased breath sounds and bilateral basilar crackles. There was moderate right upper quadrant tenderness, left flank tenderness, and an osler node at his left middle finger, along with 3+ pitting edema in bilateral lower extremities.BNP was 10424 pg/mL, sodium 133 mmol/L, leukocyte count 8.76 k/uL, hemoglobin 10.9 g/dL, AST 106 U/L, and ALT 105 U/L. Transthoracic echo showed findings consistent with right heart failure secondary to left heart failure, volume overload, and a large mitral valve vegetation. CT chest showed bilateral pleural effusions, right upper lobe consolidation consistent with pneumonia, and scattered opacities suggestive of pulmonary edema. Blood culture speciation grew Kodamaea ohmeri with susceptibility to Amphotericin.Given two previous valve replacement failures, patient was deemed a poor surgical candidate by cardiothoracic surgery. He was started on Amphotericin 5mg/kg/day for fungemia endocarditis and Ceftriaxone for pneumonia. Despite repeat blood cultures showing no growth after 2 days, the patient later developed acute renal failure secondary to poor cardiac perfusion along with an acute transaminitis secondary to congestive hepatopathy. The patient ultimately decided to withdraw care, dying a few days later.
Discussion: Formerly known as Pichia ohmeri, Kodamaea ohmeri is a rare fungus that belongs to the same family as candida. It has previously been described in tree bark, fruits, salts used in the fermentation of pickled vegetables, sea water, pools, and sand. First reported in 1998, there has recently been an increasing number of identified cases of deadly, systemic Kodamaea infections.Per literature review, 73 cases of fungemia have been identified to date, with only 3 resulting in endocarditis. Mainly occurring in immunocompromised individuals, other invasive infections of Kodamaea include peritonitis, cellulitis, and catheter-related urinary tract infection. Occurrence in immunocompetent individuals is rare.Reassuringly, Kodamaea has frequently shown sensitivity and successful treatment with Amphotericin B, as was the case with our patient. His cultures additional showed sensitivity to echinocandins, however, there is limited data with their use as Amphotericin is typically the anti-fungal of choice.
Conclusions: Fungal endocarditis is a rare life-threatening condition that is at increased risk following interventional procedures. Even more rare is the colonization with Kodamaea ohmeri, as this is only the 4th case of endocarditis reported to date. Preventive measures and avoidance of pre-disposing risk factors should be stressed post-operatively, especially in those who are immunocompromised.