Exophiala species--a rare cause of endocarditis with cerebral abscess formation

Exophiala species belong to the dematiaceous fungi. Occurring worldwide, they are a rare cause of human infection. We present the case of a 75-year-old immunocompetent patient with a cardiogenic embolic anterior cerebral artery infarction. Echocardiography revealed endocarditis of the aortic valve. Antibiotic therapy was initiated after susceptibility testing (blood cultures were positive for Staphylococcus aureus, and liquor was normal), with a subsequent fall in serologic markers of infection and resolution of the signs of endocarditis on echocardiography. However, 6 weeks after initiation of antibiotic therapy, abscesses were seen in the infarct region on CT scan, although antimicrobial treatment was still continued. At this stage, the CSF showed an inflammatory process, and Exophiala species, susceptible to voriconazol, could be detected in liquor cultures. However, antifungal therapy with voriconazol could not prevent severe sepsis and death from multiorgan failure. Autopsy revealed the clinically supposed Exophiala endocarditis with metastatic cerebral abscesses. In accordance with other published case reports, a fatal outcome in disseminated Exophiala infection might only be prevented by aggressive therapy consisting of early surgical removal of the foci and combined antifungal agents.