Aspergillus fumigatus pacemaker lead endocarditis: A case report and review of the literature

Abstract

Fungal endocarditis is an uncommon complication of pacemaker implantation and is associated with high mortality rates (1). Survival is largely dependent on early diagnosis and treatment. However, late diagnosis is common due to the frequency of nonspecific clinical symptoms, negative blood cultures and delays in obtaining appropriate imaging studies. A high index of suspicion for fungal endocarditis should be maintained in individuals with implantable pacemakers and fever of an uncertain source, especially in the context of negative blood cultures. We report a patient with rare pacemaker lead endocarditis due to Aspergillus fumigatus, and review the diagnostic and treatment considerations. CASE PRESENTATIONA 71-year-old man was admitted with a two-week history of chest pain and a one-week history of low-grade fever (less than 39°C). His medical history was significant for myocardial infarction, atrial fibrillation and asystolic arrest, leading to pacemaker insertion 23 years previously. Numerous pacemakerrelated complications had led to five pacemaker revisions. Superior vena cava (SVC) syndrome, secondary to pacemaker lead fibrosis, was treated on two separate occasions with percutaneous catheter dilation and stenting, most recently performed four months before presentation. He was receiving chronic anticoagulation with warfarin, and antiplatelet therapy consisting of acetylsalicylic acid and clopidogrel. He had no history of being immunocompromised.Physical examination revealed a temperature of 38.5°C. Chronic plethora due to longstanding SVC obstruction was observed. There were no cardiac murmurs or extra heart sounds. No stigmata of infectious endocarditis were observed. The remainder of the physical examination was unremarkable. Pertinent laboratory data included a hemoglobin count of 113 g/L, white blood cell count of 3.8×10 9 /L, platelet count of 153×10 9 /L, erythrocyte sedimentation rate of 102 mm/h, C-reactive protein concentration of 163 mg/L and international normalized ratio of 2.8. There was no biochemical or electrocardiographic evidence of myocardial infarction. Multiple blood cultures performed during the patient's sixweek admission were negative and no antimicrobial therapy was initiated. The diagnosis of fungal endocarditis requires a high index of clinical suspicion. Rarely, pacemaker implantation may be a risk factor for the development of fungal endocarditis. A 71-year-old man with a history of multiple transvenous pacemaker manipulations and fever of an uncertain source is described. A diagnosis of culture-negative pacemaker endocarditis was established only after repeat transthoracic echocardiography. Amphotericin B was instituted; however, the patient developed a cerebral infarct and died. Postmortem examination demonstrated Aspergillus fumigatus within a large pacemaker lead thrombus, tricuspid and aortic valve vegetations, and septic pulmonary and renal emboli. The present report describes the clinical and pathological features of a rare case of Aspergillus fumigatus pacemaker lead en...

A Rare Entity–Percutaneous Lead Extraction in a Very Late Onset Pacemaker Endocarditis: Case Report and Review of Literature

“…Very late lead-related endocarditis is a rare entity, with sporadic mentions. After a literature search, we found only four lead-related endocarditis cases reported after more than 10 years since implantation [ 22 , 23 , 24 , 25 ], of which one patient had catheter dilation and stenting for superior vena cava syndrome (secondary to pacemaker lead fibrosis) performed four months before endocarditis diagnosis, a procedure that probably led to vegetation formation [ 24 ]. Two more cases of late lead endocarditis are described: the first, 7 years after initial implant [ 26 ] and the second, fungal endocarditis in an immunocompromised host, 9 years after implant [ 27 ].…”

Aspergillus Sphenoiditis Associated with an Artificial Bone Graft Used for Transsphenoidal Surgery

“…Fungi can colonize implanted foreign bodies such as central venous catheters, pacemaker leads, and prosthetic joints, resulting in systemic complications. [8][9][10][11] Feely and Steinberg described two cases of Aspergillus infection caused by a transsphenoidal 90 Y pituitary implant mounted on stainless steel screws to destroy the pituitary by interstitial irradiation. 12) To the best of our knowledge, this is the first report of Aspergillus infection in an artificial bone graft.…”

A Case of Late Implantable Cardiac Device Infection with Aspergillus in an Immunocompetent Host

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