"LEADING TO DANGER": A CASE OF INFECTIVE ENDOCARDITIS INVOLVING AN AUTOMATIC IMPLANTABLE CARDIAC DEFIBRILLATOR LEAD

Abstract

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Patients with presence of intracardiac devices are at an increased risk of developing endocarditis. In this report we present a patient with an automatic implantable cardiac defibrillator (AICD) who presented with atypical symptoms found to have a significant vegetation involving the AICD lead who required emergent removal of the cardiac device and ultimately expired. CASE PRESENTATION: A 58-year-old male with history of lung cancer and ischemic cardiomyopathy status post AICD placement presented to the emergency department with low back pain. Physical exam was remarkable for tenderness to palpation of his lumbar region. The patient was found to have a leukocytosis, but was afebrile and without other signs of infection. Imaging of his spine did not reveal any apparent etiology for his back pain. Blood cultures obtained at presentation grew gram positive cocci in four of four bottles and ultimately speciated as MSSA. A transthoracic echocardiogram was performed and revealed a large vegetation on the tricuspid valve with concern for involvement of the AICD lead. Given these findings he underwent emergent surgery for lead and device extraction. During the procedure the patient became bradycardic and hypotensive and went into cardiac arrest. Despite maximum resuscitative efforts the patient expired. DISCUSSION: Infective endocarditis (IE) is a highly morbid and deadly infection involving the endocardium, the lining of the inside of the heart and heart valves. Right-sided endocarditis is less common, making up approximately 5% to 10% of all cases. It is most commonly associated with intravenous drug use, central venous catheters, and the presence of intracardiac devices. The prevalence of right-sided endocarditis has increased over the past several decades due to the increase in the aforementioned risk factors. Unique complications of right-sided endocarditis include the risk of septic pulmonary emboli, pneumonia, and the formation of a pulmonary abscess. In cases where implantable cardiac devices are present the mainstay of treatment includes not only antibiotics, but also the complete extraction of the device and leads. Studies have shown that early diagnosis and lead extraction of infected cardiac devices are associated with lower in-hospital mortality. CONCLUSIONS: Patients with intracardiac devices are at increased risk of developing infective endocarditis and their clinical presentation maybe atypical, such as back pain in our patient. It is of paramount importance to perform early diagnostic tests and prompt device removal in such cases. Clinicians must be aware of the increased risk in such a population in order to facilitate early detection and appropriate intervention. REFERENCE #1: Cahill TJ, Prendergast BD. Infective endocarditis. Lancet. 2016;387(10021):882-893. doi:10.1016/S0140-6736(15)00067-7 REFERENCE #2: Hubers SA, DeSimone DC, Gersh BJ, Anavekar NS. Infective Endocarditis: A Contemporary Review. Mayo Clin Proc. 2020;95(5):982-997. doi:10.1016/j.mayocp.2019.12.008 REFERENCE #3: Shmueli H, Thomas F, Flint N, Setia G, Janjic A, Siegel RJ. Right-Sided Infective Endocarditis 2020: Challenges and Updates in Diagnosis and Treatment. J Am Heart Assoc. 2020;9(15):e017293. doi:10.1161/JAHA.120.017293 DISCLOSURES: No relevant relationships by Ahmed Aladham, source=Web Response No relevant relationships by Kyle Brockman, source=Web Response No relevant relationships by Navitha Ramesh, source=Web Response