Delayed aspergillus endocarditis and septic pulmonary embolism caused by a retained transcardiac foreign body

Abstract

Background

Retained intravascular or intracardiac foreign bodies are rare but well-recognized in the surgical literature. However, delayed septic pulmonary embolism resulting from a retained transcardiac foreign body has not been previously reported.

Case description

This case report describes a 57-year-old woman who presented with fever and cough for one month and worsening dyspnea over three days. Two years prior, she had been struck by a metallic object from a lawnmower but did not seek medical attention. Chest radiography demonstrated a linear metallic foreign body in the right lower lung field. Transthoracic echocardiography showed a rod-shaped structure confined to the right atrium, with vegetations surrounding the foreign body and extending into the right ventricle. CT angiography was subsequently performed, which identified a metallic foreign body traversing the diaphragm from the liver into the right heart, as well as emboli in the distal branches of the right pulmonary artery. Surgical exploration via median sternotomy confirmed a metallic rod measuring 10 cm in length and 0.5 cm in diameter penetrating the liver, diaphragm, and right atrium. The rod was successfully removed together with the pulmonary emboli. Pathological analysis demonstrated Aspergillus infection. The patient was discharged in stable condition and completed postoperative oral voriconazole therapy.

Conclusions

Although penetrating cardiac foreign bodies may initially be nonfatal, the present case illustrates their potential for late-onset fungal colonization and embolic complications, highlighting the importance of timely surgical removal and vigilant follow-up.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12893-026-04055-z.

Background

Cardiac foreign bodies are rare and may enter the heart via various routes [1]. The clinical presentation exhibits marked heterogeneity, ranging from completely asymptomatic to acute cardiac tamponade and sudden death. Plain radiography, computed tomography, and echocardiography are the primary diagnostic modalities. Treatment strategies should be individualized, taking into account the size, shape, location of the foreign body, and hemodynamic status. Treatment options include surgical removal, percutaneous removal, or conservative management [2].

A literature search of PubMed and Web of Science over the past ten years, using the keywords “cardiac foreign body” and “endocarditis”, yielded 43 relevant articles, including 31 case reports. The basic information of these cases is summarized in Supplementary Table 1. Notably, none of the reported cases involved a cardiac foreign body traversing the liver and subsequently leading to delayed fungal endocarditis and pulmonary embolism, which further supports the novelty of our case. To our knowledge, this is the first reported case of a retained transcardiac foreign body traversing the heart and liver leading to delayed septic pulmonary embolism.

Case presentation

A 57-year-old female farmer presented with persistent fever and cough for one month, maximum temperature of 39.4 °C, which worsened over three days with progressive dyspnea. She received cephalosporin antibiotic treatment at a local hospital without clinical improvement and was subsequently transferred to our institution. On admission, her axillary temperature was 38.5 °C. Laboratory findings showed several abnormalities, white blood cell count (WBC) 15.09 × 10⁹/L (reference range 3–9 × 10⁹/L), hemoglobin (Hb) 89 g/L (reference range 112–149 g/L), C-reactive protein (CRP) 129 mg/L (reference range 0–4 mg/L), procalcitonin(PCT) within normal limits, serum albumin(ALB) 34.7 g/L (reference range 35–50 g/L), D-dimer 1,880 µg/L (reference range < 500 µg/L). Serum (1,3)-β-D-glucan (G test) and galactomannan (GM test) were performed on admission, prior to empirical antibiotic therapy, and both yielded negative results. Blood cultures for bacteria and fungi, as well as sputum cultures, were negative. Chest radiography demonstrated a linear metallic foreign body in the right lower lung field (Fig. 1 panel A).

Fig. 1.

Multimodality imaging and intraoperative findings of the retained transcardiac foreign body. A Chest radiography shows a linear metallic foreign body in the right lower lung field. B Transthoracic echocardiography reveals a rod-shaped hyperechoic foreign body in the right atrium (RA) with vegetations extending into the right ventricle (RV). C CT angiography confirms the metallic rod penetrating the diaphragm from the liver into the right heart. D CT Pulmonary angiography demonstrates filling defects (emboli) in distal branches of the right pulmonary artery (PA). E The intraoperative photograph shows the extracted metallic rod, measuring 10 cm in length and 0.5 cm in diameter. F Rod-shaped foreign bodies and septic vegetations. Histopathological examination of the vegetations showed Aspergillus hyphae (H&E stain, ×20, inset). LV, left ventricle. LA, left atrium

Further history taking revealed that two years earlier, the patient had been struck by a foreign body while operating a lawnmower. She experienced chest discomfort at that time but did not seek medical evaluation due to the absence of bleeding. Over the subsequent two years, she had an unintentional weight loss of 15 kg.

Transthoracic echocardiography showed a rod-shaped hyperechoic foreign body in the right atrium, with vegetations visible around the rod-shaped structure, extending into the right ventricle (Fig. 1 panel B). Empirical anti-infective therapy with cefoperazone/sulbactam plus vancomycin was administered for one week, with no clinical improvement. Further imaging with computed tomography angiography was performed, which identified a metallic foreign body traversing the diaphragm from the liver into the right heart (Fig. 1 panel C) and revealed emboli in the distal branches of the right pulmonary artery (pulmonary embolus, Fig. 1 panels D).

Following multidisciplinary team discussion, the patient underwent a median sternotomy. The operation was performed under mild hypothermic (34–35 °C) beating-heart cardiopulmonary bypass, with arterial cannulation of the ascending aorta and venous drainage via the superior vena cava and femoral vein. Surgical exploration revealed a metallic rod measuring 10 cm in length and 0.5 cm in diameter, penetrating the liver, diaphragm, and right heart. The metallic foreign body was extracted via a right atriotomy, and the pulmonary emboli were removed through a direct pulmonary arteriotomy. Both were successfully retrieved (Fig. 1, panels E and F). The total operative time was 90 min. Pathological analysis of the debrided vegetations and pulmonary emboli showed positive staining for periodic acid–Schiff (PAS) and Gomori methenamine silver (GMS). The microscopic findings of septate hyphae with acute-angle branching (~ 45°) and uniform width findings were highly consistent with Aspergillus infection (Fig. 1F, inset, H&E stain, ×20). The patient was discharged uneventfully on postoperative day 10 and continued oral voriconazole (200 mg twice daily) for a planned duration of 12 weeks, with therapeutic drug monitoring (target trough, 1–5.5 µg/mL) and monthly liver function tests, along with regular medical follow‑up.

Follow-up at 3 months demonstrated satisfactory clinical recovery, with normalization of body temperature, WBC, CRP, fungal blood cultures, and echocardiographic findings. At more than 11 months postoperatively, the patient remained asymptomatic, resumed normal daily activities, showed no signs of infection, and achieved a 6‑minute walk test distance of 625 m.

Discussion

Retained cardiac foreign bodies are rare, with most cases resulting from penetrating trauma, intravenous migration, or iatrogenic retention. Complications caused by cardiac foreign bodies include mechanical injury, arrhythmias, infection, and embolism. The risk of these complications is closely related to the size, location, type, and duration of retention of the foreign body. The extent of impact also varies depending on the location where the foreign body lodges [1]. Although the clinical spectrum ranges from incidental findings to life-threatening cardiac tamponade or systemic embolism, delayed complications occurring years after the initial insult remain exceptional. To our knowledge, the present case is the first to describe a transcardiac foreign body traversing the liver and diaphragm, presenting with delayed septic pulmonary embolism secondary to Aspergillus infection two years after the penetrating injury.

Two unique features of this case warrant particular attention. First, despite a metallic rod penetrating the liver, diaphragm, and right atrium, the patient remained completely asymptomatic for two years after the initial injury. The delayed presentation may be partly attributed to the possible mechanism that the foreign body was fixed and stable, and did not cause life‑threatening complications such as hemorrhage or cardiac tamponade. Second, the possibility of Aspergillus endocardial infection should not be ruled out by negative serum fungal biomarkers and cultures. Serum fungal biomarkers may remain negative in localized Aspergillus endocarditis because of the limited fungal burden within the bloodstream and the absence of disseminated disease. In the present case, both the vegetations and pulmonary emboli showed Aspergillus infection, an extremely rare finding in penetrating cardiac foreign bodies. Given the patient’s occupation as a farmer and the circumstances of the lawnmower injury, the source of Aspergillus was likely environmental. Unlike bacterial endocarditis, Aspergillus cardiac infections are often characterized by normal procalcitonin levels, negative blood cultures, and a subacute or indolent course, as observed in this patient. These features can easily lead to misdiagnosis or delayed diagnosis, emphasizing the need for a high index of suspicion for fungal etiology in patients with negative routine cultures and a history of penetrating trauma.

Regarding management, surgical removal was unequivocally the preferred option in this case. The foreign body was long, sharp, and carried vegetations. It traversed multiple organs and had already caused septic pulmonary embolism. Surgical exploration allowed en bloc removal of the foreign body and pulmonary emboli under direct vision. Postoperatively, oral voriconazole was administered as antifungal therapy, which is the standard treatment for Aspergillus endocarditis [3–4]. The optimal duration remains uncertain, but current guidelines generally recommend at least 12 weeks, followed by long‑term surveillance for relapse [5–6].

We acknowledge that the diagnosis of Aspergillus infection in this case was based on histopathological findings alone, without fungal culture or molecular confirmation. This precludes species‑level identification and represents a limitation of this report Table 1.

Table 1.

31 case reports of cardiac foreign body and endocarditis in the past ten years

Title	foreign body type	location	microbiology	outcome
Intracardiac foreign body: A rare cause of recurrent fungemia	tooth-pick	right atrium	Candida albicans and Streptococcus constellatus	alive
Mycobacterium chelonae infection of a cardiovascular bioprosthesis linked to a recent outbreak	biological Valve	aortic valve position	Mycobacterium chelonae	alive
Tricuspid Valve Infective Endocarditis in a Chronic Haemodialysis Patient with a Hickman Catheter: A Case Report	permanent-Hickman catheter	permanent-Hickman catheter and the tricuspid valve	Enterococcus spp	alive
Surgicel mimicking early onset prosthetic valve endocarditis: case report	surgicel	periaortic echogenic mass	No	alive
Percutaneous Removal of Epicardial Pacing Wire: Nidus for Infective Endocarditis	epicardial Pacing Wire	tricuspid valve and right atrium	Staphylococcus epidermidis	alive
A Case of Pacemaker Associated Aspergillus fumigatus Endocarditis	pacemaker	subtricuspid region of pacemaker lead	Aspergillus fumigatus	alive
Native Tricuspid Valve Infective Endocarditis After Breast Skin Abscess	left breast skin abscess	tricuspid valve	Methicillin-resistant Staphylococcus aureus	alive
Right ventricular outflow tract endocarditis caused by brucellosis	no	right ventricular outflow	Brucellosis	alive
A shrapnel migration from a peripheral vein to the right ventricle: case report	shrapnel	right ventricle	No	alive
Concomitant endocarditis and spondylodiscitis due to coagulase-negative Staphylococci and a review of the literature	cardiac device	right heart	S. epidermidis, and S. haemolyticus.	alive
Infections due to Cellulosimicrobium species: case report and literature review	aortic prosthetic valve	aortic valve	Cellulosimicrobium species	death
Periprosthetic joint infection caused by kytococcus schroeteri: The first reported case and a review of the literature	periprosthetic	joint	Kytococcus schroeteri	alive
Mitral valve regurgitation and endocarditis triggered by a needle	needle	mitral valve	No	alive
Penetrating thorn in the heart complicated by infective endocarditis	thorn	left ventricle	No	alive
Iatrogenic Infective Endocarditis in Hemodialysis Patients: A Case Report and Review of the Literature	arteriovenous fistula and nonleadless pacemaker	heart	methicillin-sensitive Staphylococcus aureus	death
Rare Iatrogenic Cardiovascular Embolization Following Dialysis	dialysis catheter and guidewire coating	heart and lung	No	Death
Case Report: Complex tricuspid valve repair and entrapped right ventricle foreign body extraction in an IVDU patient-early diagnosis and treatment considerations	metallic foreign body	right ventricle	Staphylococcus aureus	alive
Endarteritis of coarctation of the aorta diagnosed with PET-CT	no	descending aorta	Methicillin-sensitive Staphylococcus aureus	alive
A Rare Experience of Infective Residual Sheath in the Wall of the Innominate Vein after Extraction of Implantable-Defibrillators	implantable-defibrillators	Innominate vein	Pseudomonas bacteremia	alive
Pharmacological options for Candida albicans Endocarditis at the roadblock with irrecoverable prosthetics and drug interactions: a case report and review of literature	prosthetics	heart	Candida albicans	alive
Conservative non-surgical management of penetrating cardiac injury with three retained metal nails: a case report	metal nails	heart	Staphylococcus epidermidis	death
Intramuscular Migration of Venous Catheter as a Rare Complication of Ventriculoatrial Shunt: Case Report and Literature Review	venous Catheter	intramuscular migration	No	alive
Dyspnoea Due to Foreign Embolism after Percutaneous Vertebroplasty	toothpick-like structure	right ventricle	Yes	death
The dark side of the fibroblastic sleeve: Case report and literature review	midline catheter	tricuspid valve	No	alive
Candida parapsilosis endocarditis in an intravenous drug abuser: an autopsy report	no	heart	Candida parapsilosis	death
A Neglected Case of Infective Pacing Wire Endocarditis	pacing Wire	heart	Not Available	Not Available
Symptomatic Intracranial Artery Stenosis Due to an Unknown Embolus Following Cardiac Surgery: A Case Report	blood clot	symptomatic intracranial artery stenosis	Not Available	alive
Fighting fungus with a laser and a hose: Management of a giant Candida albicans implantable cardioverter-defibrillator lead vegetation with simultaneous AngioVac aspiration and laser sheath lead extraction	internal cardiac devices	right atrial	Fungus	not applicable
Aorto-pericardial fistula in an intravenous drug addict with infective endocarditis of the aortic valve	no	aortic valve	Not Available	death
A “UFO” in the right pulmonary artery after cardiac surgery	not Available	right pulmonary artery	Not Available	not available
Successful treatment of an acute infective endocarditis secondary to fish bone penetrating into left atrium caused by Granulicatella adiacens and Candida albicans: A case report	fish bone	left atrium	G adiacens and C albicans	alive
Usefulness of 18 F-fluorodeoxyglucose positron emission tomography/computed tomography angiography in a patient with blood culture-negative prosthetic valve endocarditis complicated with perivalvular abscess: a case report	prosthetic valve	aortic valve	No	alive

Conclusions

This case demonstrates that penetrating cardiac foreign bodies may be initially non‑fatal but carry a latent risk of late‑onset fungal infection and septic embolism. Clinicians should be aware of this rare but potentially fatal complication, particularly in patients with an indolent course, negative routine cultures, and a history of penetrating trauma. Meanwhile, it highlights the value of a high index of suspicion, timely multimodality imaging, and aggressive surgical intervention combined with targeted antifungal therapy.

Authors' contributions

Lu Tong and Fei Li wrote the main manuscript text,Cheng Zhou and Nianguo Dong prepared figures 1. All authors reviewed the manuscript.

Funding

None.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Formal ethical approval was waived by the Institutional Review Board of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology due to the retrospective nature of this single case report. The patient provided written informed consent for publication.

Competing interests

The authors declare no competing interests.