Cardiac aspergillosis: endocardial or endomyocardial?

We read with great interest the article by Kalokhe et al., in which the authors presented a case of cardiac device-related Aspergillus endocarditis in a patient with a pacemaker and also made an effort to collect and review the related cases in the literature. We would like to share our case of endomyocardial invasive aspergillosis, which was not cited in their review. Although it is well known that exposure to Aspergillus organisms/spores is common, the disease caused by tissue invasion with these fungi is, however, uncommon and occurs primarily in the setting of immunosuppression. In 2005 we reported a case of rapidly advancing invasive endomyocardial aspergillosis secondary to prolonged usage of multiple broadspectrum antibiotics in a non-immunocompromised host. A 36year-old cotton textile worker presented to our institution with a 3-month history of weight loss and fatigue. He reported the prolonged use of multiple broad-spectrum antibiotic treatment. An echocardiogram demonstrated multiple endomyocardial vegetations and a mass in the left atrium. A myocardial biopsy specimen revealed an invasive endomyocardial aspergillosis. Treatment was started with amphotericin B and heparin for a presumed left atrial thrombus. The patient died because of a rupture of the mycotic aneurysm that resulted in a cerebral hemorrhage. This case illustrates the risk of an invasive fungal infection in a non-immunocompromised host who has been exposed to prolonged use of antibiotics in the setting of environmental exposure to opportunistic invasive fungal infections. We also underline the need to avoid the use of heparin in this setting due to the risk of cerebral hemorrhage with the possible existence of a mycotic aneurysm, which might lead to fatal outcome. We would also like