Fungal Endocarditis: Pathophysiology, Epidemiology, Clinical Presentation, Diagnosis, and Management

Fungal endocarditis accounts for 1% to 3% of all infective endocarditis cases, is associated with high morbidity and mortality (>70%), and presents numerous challenges during clinical care. <i>Candida</i> spp. are the most common causes of fungal endocarditis, implicated in over 50% of cases, followed by <i>Aspergillus</i> and <i>Histoplasma</i> spp. Important risk factors for fungal endocarditis include prosthetic valves, prior heart surgery, and injection drug use. The signs and symptoms of fungal endocarditis are nonspecific, and a high degree of clinical suspicion coupled with the judicious use of diagnostic tests is required for diagnosis. In addition to microbiological diagnostics (e.g., blood culture for <i>Candida</i> spp. or galactomannan testing and PCR for <i>Aspergillus</i> spp.), echocardiography remains critical for evaluation of potential infective endocarditis, although radionuclide imaging modalities such as ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography are increasingly being used. A multimodal treatment approach is necessary: surgery is usually required and should be accompanied by long-term systemic antifungal therapy, such as echinocandin therapy for <i>Candida</i> endocarditis or voriconazole therapy for <i>Aspergillus</i> endocarditis.