Case Study
Aspergillus pacemaker lead endocarditis Jeewan Pillai, Mohammad Mubeen, Amit Chaudhari and Basant Dalmia
Asian Cardiovascular & Thoracic Annals 21(2) 211–214 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312450448 aan.sagepub.com
Abstract A 47-year-old man who had a pacemaker implanted 2 years earlier, recently developed a fever and had been on antibiotics for 2 months. He presented with pulmonary emboli, and underwent lead extraction and emboli removal. Histopathology demonstrated Aspergillus. Amphotericin B was continued postoperatively. This rare case of pacemaker lead endocarditis suggests that vigorous medical and surgical intervention can be curative.
Keywords Antifungal agents, aspergillus fumigates, echocardiography, endocarditis, pacemaker
Introduction Fungal endocarditis is an uncommon complication of pacemaker implantation, associated with high morbidity and mortality rates >50% regardless of treatment.1 A combined medical-surgical approach seems to offer an improved outcome. However, there are no clinical trials to support this opinion, largely because of the rarity of the condition. A high index of suspicion of fungal endocarditis should be maintained in individuals with implantable pacemakers and fever of an uncertain origin.
Case report A 47-year-old man, a known hypertensive, was admitted with a 4-week history of high-grade fever with chills and rigors. His medical history was significant as he had been diagnosed with dilated cardiomyopathy and had undergone implantation of a cardioverter-defibrillator. Routine investigations and chest radiography were suggestive of pneumonia. He had been receiving broadspectrum antibiotics for the fever that was possibly due to pneumonia. He was found to be febrile and in dyspnea class IV. Cardiac examination revealed a short systolic murmur at the left sternal border. Echocardiography revealed a mass in the right atrium near the tricuspid valve, and stigmata of infectious endocarditis were observed. Pertinent laboratory data included hemoglobin of 9.5 gdL 1, a white blood cell count of 2.05 109L 1, and deranged kidney function
(urea 69.9 mgdL 1, creatinine 1.4 mgdL 1). After multiple blood cultures (bacterial and fungal), empiric antibiotic therapy was started. On account of a very high suspicion of fungal vegetation, an injection of liposomal amphotericin B was given along with sulbactam, ampicillin, and gentamicin. Two-dimensional echocardiography revealed no regional wall motion abnormality, an ejection fraction of 61%, and a large 3.2 1.7-cm mobile mass in the right atrium (RA), prolapsing into the right ventricle, and attached to the pacemaker lead and the tricuspid valve. Transthoracic echocardiography demonstrated a large vegetation (3.2 1.8 cm) engulfing the lead and prolapsing in and out of the tricuspid valve, and a small thrombus of 0.6 to 0.7 cm in the RA (Figure 1). Chest computed tomography revealed patchy pneumonitis of the right middle zone (Figure 2). Because of the large intracardiac vegetation and pulmonary shadow suggestive of embolism, surgical removal of the RA mass along with the lead and generator was planned. Adequate hydration and antibiotics resulted in improvement of renal function, and the patient underwent surgery. Cardiopulmonary bypass was instituted after full heparinization. The RA was Department of Cardiothoracic Surgery, Delhi Heart and Lung Institute Super Speciality Hospital, New Delhi, India Corresponding author: Jeewan Pillai, MCh, Department of Cardiothoracic Surgery, Delhi Heart and Lung Institute Super Speciality Hospital, 3-MM II, Panchkuian Road, New Delhi 110055, India. Email: [email protected]
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Figure 1. Preoperative transesophageal echocardiogram showing the mass attached to the lead in the right atrium.
opened obliquely. The infected lead with the vegetation was carefully dissected off the wall of the RA. It was removed after dissection at the superior vena caval-RA junction (Figure 3). The tip of the lead was found penetrating the septal leaflet of tricuspid valve. This was repaired using 4/0 Prolene suture. The generator and the remaining lead were removed from the generator pocket. The RA was closed. Postoperatively, the antibiotic and antifungal therapy was continued. The patient became afebrile after 5 days. Histopathology of mass showed Aspergillus fungal hyphae (Figure 4), which was confirmed by culture of the mass. All blood cultures were sterile. The antibiotics were discontinued, and antifungal treatment with liposomal amphotericin B was continued. Fever recurred on the 8th day, requiring an increased dose of amphotericin B to 5 mg per kilogram of body weight and voriconazole 200 mg twice daily. The patient improved over the next 3–5 days, and generally remained afebrile thereafter. After 5 weeks of therapy, amphotericin B was stopped, and he was discharged on voriconazole. As his left ventricular function was normal, a new implantable cardioverterdefibrillator was not implanted.
Discussion Fungal organisms account for 1% to 10% of cases of infective endocarditis.1,2 A recent review of 152 cases of
fungal endocarditis attributed 39 (25%) to molds and 28 (18%) to Aspergillus species.1 To our knowledge, there have only been 3 reported cases of Aspergillus fumigatus pacemaker lead endocarditis.3,4 The early diagnosis of fungal endocarditis is often elusive. Thus unacceptably high mortality rates persist. Aspergillus species endocarditis mortality rates are greater than 90%, regardless of treatment modality.1,4 Blood cultures for Aspergillus species endocarditis are reported to be positive in only 11% of cases.6,7 Major emboli are present in approximately 83% of Aspergillus cases.6,7 Echocardiography has reported sensitivities of between 54% and 80% in detecting fungal endocarditis.2 Transesophageal echocardiography has superior sensitivity in detecting pacemaker lead vegetations, and a recent review cites the sensitivity of transesophageal echocardiography to be in excess of 90%; the sensitivity of transthoracic echocardiography is less than 30%.5 In our case, the vegetation was visible on both transthoracic and transesophageal echocardiography, however, the delineation was better with transesophageal echocardiography. Although rare cases of fungal endocarditis have been effectively treated with antimycotic therapy alone, combined medical and surgical removal of infected valves and any accompanying hardware are the mainstay of treatment.5–7 Amphotericin B is the antimycotic of choice, with recommended total
Downloaded from aan.sagepub.com at SUNY HEALTH SCIENCE CENTER on March 21, 2015
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Figure 2. Preoperative chest computed tomography scan showing emboli in the right middle zone of the lung.
Figure 3. The extracted pacemaker and lead with the fungal mass.
Figure 4. Histopathology showing fungal hyphae (Aspergillus). Hematoxylin and eosin stain, original magnification 100.
doses of 2 to 3 g (50 mgkg 1).6,7 Once bulky vegetations have formed, it is unlikely that antifungal chemotherapy alone will be sufficient. Surgery to remove the principal foci within the heart, followed
by prolonged postoperative treatment should be planned. For pacemaker lead endocarditis, thoracotomy is usually advocated when vegetations exceed 1.0 cm in size, because the risk of embolization is
Downloaded from aan.sagepub.com at SUNY HEALTH SCIENCE CENTER on March 21, 2015
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Asian Cardiovascular & Thoracic Annals 21(2)
significantly increased with intravascular traction methods.5 Pacemaker lead endocarditis is a rare complication of pacemaker implantation, and a high index of clinical suspicion of endocarditis is required in the case of fever of unknown origin in patients with transvenous pacemakers. Such patients should be subjected to transthoracic, and preferably transesophageal echocardiography, to rule out vegetations, particularly when the blood cultures are sterile. Once the diagnosis of fungal pacemaker lead endocarditis is confirmed, the patient should undergo urgent surgery for extraction of the vegetation along with the leads and the pacemaker. Antifungals need to be continued in the postoperative period for at least 2 years; some even advocate lifelong medication. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Pierrotti LC and Baddour LM. Fungal endocarditis, 1995–2000 [Review]. Chest 2002; 122: 302–310. 2. Ellis M. Fungal endocarditis [Review]. J Infect 1997; 35: 99–103. 3. Kramer L, Rojas-Corona RR, Sheff D and Eisenberg ES. Disseminated aspergillosis and pacemaker endocarditis. Pacing Clin Electrophysiol 1985; 8: 225–229. 4. Chambers J, Blauth C, Bucknall C and Eykyn S. Images in clinical medicine. Aspergilloma as a complication of pacemaker implantation. N Engl J Med 2002; 346: 428. 5. Rallidis LS, Komninos KA and Papasteriadis EG. Pacemaker-related endocarditis: the value of transesophageal echocardiography in diagnosis and treatment. Acta Cardiol 2003; 58: 31–34. 6. Bo¨hm A, Ba´nyai F, Pre´da I and Za´molyi K. The treatment of septicemia in pacemaker patients. Pacing Clin Electrophysiol 1996; 19: 1105–1111. 7. Mehta G. Aspergillus endocarditis after open heart surgery: an epidemiological investigation. J Hosp infect 1990; 15: 245–253.
Conflicts of interest statement None declared.
Downloaded from aan.sagepub.com at SUNY HEALTH SCIENCE CENTER on March 21, 2015
Aspergillus pacemaker lead endocarditis Jeewan Pillai, Mohammad Mubeen, Amit Chaudhari and Basant Dalmia
Asian Cardiovascular & Thoracic Annals 21(2) 211–214 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312450448 aan.sagepub.com
Abstract A 47-year-old man who had a pacemaker implanted 2 years earlier, recently developed a fever and had been on antibiotics for 2 months. He presented with pulmonary emboli, and underwent lead extraction and emboli removal. Histopathology demonstrated Aspergillus. Amphotericin B was continued postoperatively. This rare case of pacemaker lead endocarditis suggests that vigorous medical and surgical intervention can be curative.
Keywords Antifungal agents, aspergillus fumigates, echocardiography, endocarditis, pacemaker
Introduction Fungal endocarditis is an uncommon complication of pacemaker implantation, associated with high morbidity and mortality rates >50% regardless of treatment.1 A combined medical-surgical approach seems to offer an improved outcome. However, there are no clinical trials to support this opinion, largely because of the rarity of the condition. A high index of suspicion of fungal endocarditis should be maintained in individuals with implantable pacemakers and fever of an uncertain origin.
Case report A 47-year-old man, a known hypertensive, was admitted with a 4-week history of high-grade fever with chills and rigors. His medical history was significant as he had been diagnosed with dilated cardiomyopathy and had undergone implantation of a cardioverter-defibrillator. Routine investigations and chest radiography were suggestive of pneumonia. He had been receiving broadspectrum antibiotics for the fever that was possibly due to pneumonia. He was found to be febrile and in dyspnea class IV. Cardiac examination revealed a short systolic murmur at the left sternal border. Echocardiography revealed a mass in the right atrium near the tricuspid valve, and stigmata of infectious endocarditis were observed. Pertinent laboratory data included hemoglobin of 9.5 gdL 1, a white blood cell count of 2.05 109L 1, and deranged kidney function
(urea 69.9 mgdL 1, creatinine 1.4 mgdL 1). After multiple blood cultures (bacterial and fungal), empiric antibiotic therapy was started. On account of a very high suspicion of fungal vegetation, an injection of liposomal amphotericin B was given along with sulbactam, ampicillin, and gentamicin. Two-dimensional echocardiography revealed no regional wall motion abnormality, an ejection fraction of 61%, and a large 3.2 1.7-cm mobile mass in the right atrium (RA), prolapsing into the right ventricle, and attached to the pacemaker lead and the tricuspid valve. Transthoracic echocardiography demonstrated a large vegetation (3.2 1.8 cm) engulfing the lead and prolapsing in and out of the tricuspid valve, and a small thrombus of 0.6 to 0.7 cm in the RA (Figure 1). Chest computed tomography revealed patchy pneumonitis of the right middle zone (Figure 2). Because of the large intracardiac vegetation and pulmonary shadow suggestive of embolism, surgical removal of the RA mass along with the lead and generator was planned. Adequate hydration and antibiotics resulted in improvement of renal function, and the patient underwent surgery. Cardiopulmonary bypass was instituted after full heparinization. The RA was Department of Cardiothoracic Surgery, Delhi Heart and Lung Institute Super Speciality Hospital, New Delhi, India Corresponding author: Jeewan Pillai, MCh, Department of Cardiothoracic Surgery, Delhi Heart and Lung Institute Super Speciality Hospital, 3-MM II, Panchkuian Road, New Delhi 110055, India. Email: [email protected]
Downloaded from aan.sagepub.com at SUNY HEALTH SCIENCE CENTER on March 21, 2015
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Figure 1. Preoperative transesophageal echocardiogram showing the mass attached to the lead in the right atrium.
opened obliquely. The infected lead with the vegetation was carefully dissected off the wall of the RA. It was removed after dissection at the superior vena caval-RA junction (Figure 3). The tip of the lead was found penetrating the septal leaflet of tricuspid valve. This was repaired using 4/0 Prolene suture. The generator and the remaining lead were removed from the generator pocket. The RA was closed. Postoperatively, the antibiotic and antifungal therapy was continued. The patient became afebrile after 5 days. Histopathology of mass showed Aspergillus fungal hyphae (Figure 4), which was confirmed by culture of the mass. All blood cultures were sterile. The antibiotics were discontinued, and antifungal treatment with liposomal amphotericin B was continued. Fever recurred on the 8th day, requiring an increased dose of amphotericin B to 5 mg per kilogram of body weight and voriconazole 200 mg twice daily. The patient improved over the next 3–5 days, and generally remained afebrile thereafter. After 5 weeks of therapy, amphotericin B was stopped, and he was discharged on voriconazole. As his left ventricular function was normal, a new implantable cardioverterdefibrillator was not implanted.
Discussion Fungal organisms account for 1% to 10% of cases of infective endocarditis.1,2 A recent review of 152 cases of
fungal endocarditis attributed 39 (25%) to molds and 28 (18%) to Aspergillus species.1 To our knowledge, there have only been 3 reported cases of Aspergillus fumigatus pacemaker lead endocarditis.3,4 The early diagnosis of fungal endocarditis is often elusive. Thus unacceptably high mortality rates persist. Aspergillus species endocarditis mortality rates are greater than 90%, regardless of treatment modality.1,4 Blood cultures for Aspergillus species endocarditis are reported to be positive in only 11% of cases.6,7 Major emboli are present in approximately 83% of Aspergillus cases.6,7 Echocardiography has reported sensitivities of between 54% and 80% in detecting fungal endocarditis.2 Transesophageal echocardiography has superior sensitivity in detecting pacemaker lead vegetations, and a recent review cites the sensitivity of transesophageal echocardiography to be in excess of 90%; the sensitivity of transthoracic echocardiography is less than 30%.5 In our case, the vegetation was visible on both transthoracic and transesophageal echocardiography, however, the delineation was better with transesophageal echocardiography. Although rare cases of fungal endocarditis have been effectively treated with antimycotic therapy alone, combined medical and surgical removal of infected valves and any accompanying hardware are the mainstay of treatment.5–7 Amphotericin B is the antimycotic of choice, with recommended total
Downloaded from aan.sagepub.com at SUNY HEALTH SCIENCE CENTER on March 21, 2015
Pillai et al.
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Figure 2. Preoperative chest computed tomography scan showing emboli in the right middle zone of the lung.
Figure 3. The extracted pacemaker and lead with the fungal mass.
Figure 4. Histopathology showing fungal hyphae (Aspergillus). Hematoxylin and eosin stain, original magnification 100.
doses of 2 to 3 g (50 mgkg 1).6,7 Once bulky vegetations have formed, it is unlikely that antifungal chemotherapy alone will be sufficient. Surgery to remove the principal foci within the heart, followed
by prolonged postoperative treatment should be planned. For pacemaker lead endocarditis, thoracotomy is usually advocated when vegetations exceed 1.0 cm in size, because the risk of embolization is
Downloaded from aan.sagepub.com at SUNY HEALTH SCIENCE CENTER on March 21, 2015
214
Asian Cardiovascular & Thoracic Annals 21(2)
significantly increased with intravascular traction methods.5 Pacemaker lead endocarditis is a rare complication of pacemaker implantation, and a high index of clinical suspicion of endocarditis is required in the case of fever of unknown origin in patients with transvenous pacemakers. Such patients should be subjected to transthoracic, and preferably transesophageal echocardiography, to rule out vegetations, particularly when the blood cultures are sterile. Once the diagnosis of fungal pacemaker lead endocarditis is confirmed, the patient should undergo urgent surgery for extraction of the vegetation along with the leads and the pacemaker. Antifungals need to be continued in the postoperative period for at least 2 years; some even advocate lifelong medication. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Pierrotti LC and Baddour LM. Fungal endocarditis, 1995–2000 [Review]. Chest 2002; 122: 302–310. 2. Ellis M. Fungal endocarditis [Review]. J Infect 1997; 35: 99–103. 3. Kramer L, Rojas-Corona RR, Sheff D and Eisenberg ES. Disseminated aspergillosis and pacemaker endocarditis. Pacing Clin Electrophysiol 1985; 8: 225–229. 4. Chambers J, Blauth C, Bucknall C and Eykyn S. Images in clinical medicine. Aspergilloma as a complication of pacemaker implantation. N Engl J Med 2002; 346: 428. 5. Rallidis LS, Komninos KA and Papasteriadis EG. Pacemaker-related endocarditis: the value of transesophageal echocardiography in diagnosis and treatment. Acta Cardiol 2003; 58: 31–34. 6. Bo¨hm A, Ba´nyai F, Pre´da I and Za´molyi K. The treatment of septicemia in pacemaker patients. Pacing Clin Electrophysiol 1996; 19: 1105–1111. 7. Mehta G. Aspergillus endocarditis after open heart surgery: an epidemiological investigation. J Hosp infect 1990; 15: 245–253.
Conflicts of interest statement None declared.
Downloaded from aan.sagepub.com at SUNY HEALTH SCIENCE CENTER on March 21, 2015
