QUIZ
A 78-year-old male presented for evaluation of a cold, painful left foot. He had undergone two recent hospital admissions for unexplained fever, fatigue, arthralgias, and an 8- to 10-lb. weight loss over a 4-month period. The patient had a past medical history of hypertension, hyperlipidemia, benign colon polyps, type II mixed cryoglobulinemia, and a bioprosthetic aortic valve that was placed 2 years earlier. Despite extensive evaluations during these two admissions, including three transesophageal echocardiograms that demonstrated a normally functioning aortic bioprosthesis, no diagnosis was established. Type II mixed cryoglobulinemia was documented and treated with oral steroids and brief plasmapheresis.
During the present admission, an acute arterial embolus was diagnosed, and an emergent femoral-popliteal embolectomy was performed. A foul-smelling clot was extracted and sent to the microbiology laboratory for testing. An intraoperative transesophageal echocardiogram showed a mobile vegetation on the bioprosthetic valve and +4 tricuspid regurgitation. Six days later, the patient underwent uneventful aortic valve replacement and tricuspid valve repair. Gram stains of the embolus and valve vegetation were both negative. Fungi-Fluor fungal smears of the same specimens showed many yeasts and hyphae. Routine blood cultures remained negative. No fungal blood cultures were performed.
Fig. 1.
Grocott methenamine silver (GMS) stain; magnification, ×1,000 (oil).
(For answer and discussion, see page 1194 in this issue [doi:10.1128/JCM.r02078-10])
Contributor Information
Jennifer Franceschelli, Division of Medicine, Geisinger Medical Center, Danville, Pennsylvania 17822.
Paul Bourbeau, Division of Laboratory Medicine, Geisinger Medical Center, Danville, Pennsylvania 17822.