Does Heart Failure Mask Candida Tricuspid Endocarditis?

Infective endocarditis (IE) carries high morbidity and mortality. Although minimal in incidence, fungal causes (mostly Candida species) carry the highest mortality among all cases of infective endocarditis. We describe a rare case of a 47-year-old male with a past medical history of cerebral vascular accident (CVA), heart failure with reduced ejection fraction status post (SP) automated implantable cardioverter defibrillator (AICD) placement, paroxysmal atrial fibrillation, coronary artery disease (CAD), infective endocarditis with mitral valve replacement and tricuspid valve replacement, and pulmonary hypertension who presented to the emergency department (ED) with complaints of shortness of breath and weakness for four days. The patient was admitted to the cardiac care unit (CCU) due to persistent hypotension despite being on a continuous milrinone drip at home. The patient was initially started on antimicrobial agents for sepsis most likely secondary to pneumonia. Echocardiographic imaging showed a large vegetation on the tricuspid valve; hence, blood cultures were sent and came back positive for Candida sp. Appropriate antifungals (micafungin) were added to the medication regimen, and the patient was transferred to a tertiary hospital for surgical intervention. Patients with bioprosthetic valve replacement require regular follow-ups as this would allow providers to catch symptoms of developing endocarditis and prevent disease progression. These appointments may also decrease other risk factors for the disease, including but not limited to infected lines.

Perirectal Extragastrointestinal Stromal Tumor: An Unusual Presentation.

Gastrointestinal stromal tumors (GISTs), even though rare, remain the most common mesenchymal tumors of the gastrointestinal (GI) tract. When GISTs occur outside of the GI tract, they are termed extragastrointestinal stromal tumors (EGISTs). Most GISTs arise from the stomach (50-70%) and small intestine (20-30%). A smaller percentage of these tumors also occurs in the large intestine (5%) and esophagus (2-5%). EGISTs have histopathological and molecular characteristics that are similar to GISTs. However, the precise incidence and tumor behavior of EGISTs are not fully understood. EGISTs have no specific symptoms or radiologic features, and in most cases, the presenting complaint is abdominal pain or discomfort. Yet, they tend to be more aggressive and have a worse prognosis than GISTs. Morphologic diagnosis based on microscopic examination of histological sections is the standard diagnostic procedure for GIST/EGIST. In this patient-centered study, we present a case of EGIST that originated in the anterior perirectal space, an extremely rare location; we also describe the endoscopic approach that was used to biopsy the tumor.