Endocarditis by candida spp and association with heart failure: a systematic review of case reports

Introduction

Endocarditis is a severe and potentially life-threatening pathology characterized by infection of the endocardial surface of the heart, most commonly involving the cardiac valves. Fungal endocarditis (FEC) represents a rare but highly aggressive subset of this disease; Candida species account for only 1–2% of all reported cases of endocarditis, making this condition uncommon and consequently underrepresented in large clinical studies. Candida-related FEC remains poorly studied, with limited data regarding optimal diagnostic strategies and therapeutic approaches, also being associated with high morbidity and mortality, frequently complicated by systemic embolization, persistent fungemia, and heart failure (HF).

Objective

To determine the actual evaluation and treatment of FEC caused by Candida sp. and evaluate the current literature to assess the treatment and its efficacy among patients and its association with heart failure.

Methods

A strategised search using Google Scholar, PubMed, Scopus, Elsevier, Wiley and Nature to collect case reports of FEC caused by Candida spp. published from January 2019 to May 2025. Only articles in the English language were considered. The CARE checklist for case report guidelines was used to evaluate the completeness, accuracy, and transparency of published case reports.

Results

A total of 21 case report articles were included in the final analysis, with an average score in CARE assessment of 11 (out of 13) demonstrating the quality of the articles.

Our cohort of patients in these cases was predominantly male (61.9%) with a median age of 66.1 ±8.2 years. All of the cases had a confirmed diagnosis of FEC caused by candida spp. by culture and echocardiography. In most cases (15/21, 71.4%) fever represented a main and early symptom, followed by dyspnea 10/21 (47,6%) and weakness 6/21 (28,5%). The main candida strains were C. albicans 6/21 (28,5%), C. paraspsilosis 6/21 (28,5%) and C. tropicalis 4/21 (19%). Nine of the 21 patients presented had a confirmed HF diagnosis (42,85%), although all of the patients had some type of symptoms related to Framingham criteria. The main therapy used was fluconazole, amphotericin and echinocandins (caspofungin, micanfungin and anidulafungin). Combined therapy (two or more antibiotics) was more effective, with fluconazole use being statistically significant (p=0.030)

Conclusions

FEC is associated with prosthetic valves, implantable cardiac devices, central venous catheters, immunosuppression and prolonged ICU stay. Maintaining a low diagnostic threshold in high-risk patients is critical to improving early diagnosis and HF outcome. From a therapeutic perspective, combination antifungal therapy using two or more agents (most commonly amphotericin B in combination with fluconazole or echinocandins) appears to be more effective than monotherapy.TABLE 1.Characteristics of subjectsFor image description, please refer to the figure legend and surrounding text.IMAGE 1. PRISMA endocarditis by candida.For image description, please refer to the figure legend and surrounding text.