PMC9871031_01
Echocardiography of the patient. White arrow represents a 38.6x26.2x30.0 mm vegetation adhered to right cardiac pacemaker.
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Echocardiography showed a 38.6x26.2x30.0 mm vegetation (white arrow) adhered to the right cardiac pacemaker and tiny mitral subvalvular vegetations, which aroused our concern (Figure 1).
Histopathological examination of the vegetation by HE staining. The boxes with different colors represent the presence of Aspergillus lesions, and the black arrow is used to point to the enlarged image of Aspergillus lesion in the blue box.
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Histopathological digital slices of the vegetations demonstrated multiple fibrinoid and hemorrhagic necrosis with extensive inflammatory infiltration, accompanied by hyaline sporophores and filamentous hyphae, 2-7 mum in diameter, dark in HE staining (Figure 2).
Pathogenic identification. (A) Antler-like filamentous hyphae in a background of several inflammatory cells by Gram staining of the vegetation. (B) Blue septate hyphae with branches at acute angles by fluorescence staining of the vegetation. (C) A greyish-green and velutinous colony after culture on fungal medium. (D) Lactophenol cotton blue staining of the colony. (E) Phylogram of the ITS sequence of isolating strain Aspergillus fumigatus ZJPPH1 along with 18 available sequences with the highest homology retrieved from GenBank by MEGA11.
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Antler-like filamentous hyphae were stained by Gram staining of the vegetations (Figure 3A). Septate hyphae with branches at acute angles were shown in bright blue by fluorescence staining (Figure 3B). The colony cultured from vegetations was grayish-green and velutinous (Figure 3C). Lactophenol cotton blue staining showed that the top of the smooth conidia stalk expanded to form an inverted flask-shaped top cyst with a single-layer sterigma, and unstained conidia were spherical, forming a blue chrysanthemum (Figure 3D). Aspergillus fumigatus ZJPPH1 along with 18 available sequences with the highest homology retrieved from GenBank by MEGA11 (Figure 3E). After confirming that the infection factor was Aspergillus fumigatus, we changed caspofungin to 0.2 g of voriconazole every 12 hours for anti-Aspergillus fumigatus infection treatment.