Czy powinniśmy zawsze ufać dokumentacji medycznej? Analiza przypadku chorej po implantacji kardiostymulatora z podejrzeniem jego dysfunkcji Should we always trust medical records? Analysis of the case of a patient after cardiac pacemaker implantation with suspected device dysfunction
A 67-year-old patient after DDD pacemaker implantation due to complete atrioventricular block (17.04.2014), dislocated right atrial lead (RAL) reposition and pacemaker replacement (05.03.2015), transvenous RAL extraction with implantation of a new lead (03.06.2015), and Lyme disease (1999; IgG+, IgM-) was admitted to hospital due to unexplained subfebrile conditions (≤ 37.2°C), occurring occasionally from 2015, to be diagnosed for possible cardiac device-related infective endocarditis (CDRIE). Three out of 38 blood cultures (BCs) collected from the left hand between 2015 and 2017 were positive for Staphylococcus Epidermidis; control BCs from the right hand were negative. No shivering/fever or features of pocket or general infection were observed in previous and current hospitalisations and antibiotic therapy was not used (except perioperative prophylaxis). No additional echoes were observed on transoesophageal echocardiography (TEE), or three previous TEEs (2015-2017). Twelve new control BCs were negative. Positron emission tomography/computed tomography with 18F-fluorodeoxyglucose (18F-FDG PET/CT) revealed no increase in FDG metabolism in the chest. Two locations were identified as potential sources of chronic infection: lingual tonsil/palatine tonsils and left, external iliac lymph nodes (Fig. 1A, B). CDRIE was excluded. The patient was discharged with the recommendation to perform necessary consultations to remove potential infectious foci. This case demonstrates an infection diagnostic process in a patient with a cardiac implantable electronic device (CIED) without a clear final diagnosis, following the 2009 European Society of Cardiology (ESC) guidelines [1] and their modification from 2015 [2]. According to Duke criteria (DC) for infective endocarditis (IE), the patient fulfilled one major (positive BC) and one minor (CIED) criterion, and thus was diagnosed with possible IE [1, 2]. A history of CIED/RAL-related operations and occurrence of subfebrile conditions, although not included in the DC, further increased the risk of CDRIE. Initial elevated C-reactive protein (49.9 mg/L) decreased to normal level. Procalcitonin level and white blood cell count were always within reference range. CDRIE was not confirmed by any of the TEEs. The ESC specifies an IE diagnostic algorithm for patients with CIED. According to class IC recommendation, three BC pairs should be collected [2]. In our patient, three BCs positive for Staphylococcus Epidermidis from a total of 50, drawn in large intervals (2015-2017), in individual samples and always from one limb, were considered as contamination (natural skin microorganism) after the microbiologist's consultation. However, coagulase-negative staphylococci may cause IE, so positive samples required verification. Following the guidelines (class IC) [2], TEE was performed and revealed no abnormalities. In such cases, F-FDG PET/CT is recommended (class IIbC) as the next step [2]. PET/CT did not show increased level of FDG metabolism in the chest but indicated other suspected sources...
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