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Purulent Pericarditis Due to an Infected Pacemaker Lead
1Department of Internal Medicine, LSU Health Sciences Center in New Orleans, LA.
Introduction:
Intravenous drug users have a substantially increased risk of infective endocarditis, especially in the setting of implanted cardiac devices. Purulent pericarditis is a rare occurrence that can occur iatrogenically or through direct or hematogenous spread.
Case Description:
A 75 year old man with a past medical history significant for hepatitis C, IV drug abuse, and sick sinus syndrome status post pacemaker was brought in by EMS with a chief complaint of diaphoresis and chest pain. Initial EKG revealed atrial fibrillation with ST elevations in multiple leads. The patient was taken urgently to the cardiac catheterization lab due to concern for STEMI. Left heart catheterization revealed nonobstructive CAD; bedside echo was significant for a pericardial effusion and a pacemaker lead vegetation. CT of the chest revealed extension of the ventricular pacemaker lead through the anterior right ventricular wall and pericardium and into the pleural cavity. Cardiothoracic surgery performed a pacemaker removal as well as pericardial window due to early tamponade; approximately 900 mL of purulent fluid was drained from the pericardial space. The patient was septic with initial blood cultures growing MSSA. He was also found to have multiple other foci of infection including a left-sided pleural effusion and a perihepatic fluid collection, both of which were drained and also grew out MSSA. The patient initially improved on antibiotics after his pacemaker removal and drainage of the infected fluid collections. However, several days after the pacemaker removal he gradually became more bradycardic; due to his multiple comorbidities and active infection, he was not a candidate for a replacement implanted pacemaker. He became profoundly bradycardic and hypotensive overnight and died despite the use of multiple pressors to maintain his blood pressure as well as transcutaneous pacing to maintain his heart rate.
Discussion:
Purulent pericarditis has become a relatively uncommon occurrence since the development of effective antibiotics. This case illustrates a rare example of purulent pericarditis and cardiac tamponade secondary to the extension of an infected pacemaker wire through the pericardium and into the thoracic cavity. The presence of multiple other infected fluid collections in this case also illustrates the need to thoroughly assess for secondary foci of infection in cases of bacterial endocarditis.
Insights
A rare case of purulent pericarditis and cardiac tamponade occurred in an IV drug user due to an infected pacemaker wire. Despite treatment, the patient experienced complications and died from sepsis and bradycardia.
Area of Science:
- Cardiology
- Infectious Diseases
- Medical Case Studies
Background:
- Intravenous drug users (IVDU) face elevated risks for infective endocarditis, particularly with cardiac devices.
- Purulent pericarditis is an uncommon condition, often resulting from iatrogenic causes or direct/hematogenous spread.
Purpose of the Study:
- To present a rare case of purulent pericarditis and cardiac tamponade.
- To highlight the complications arising from infected pacemaker leads in IVDU.
Main Methods:
- A case study of a 75-year-old male with a history of IV drug abuse and a pacemaker.
- Diagnostic procedures included EKG, cardiac catheterization, echocardiography, and CT scan.
- Surgical intervention involved pacemaker removal and pericardial window creation.
Main Results:
- Infected pacemaker lead extended through the right ventricular wall into the pericardial and pleural cavities.
- Patient presented with sepsis, purulent pericarditis, cardiac tamponade, and multiple infected fluid collections (pleural effusion, perihepatic).
- Despite initial improvement with antibiotics and drainage, the patient developed severe bradycardia and hypotension, leading to death.
Conclusions:
- This case demonstrates a rare instance of purulent pericarditis and cardiac tamponade caused by an infected pacemaker wire breaching the pericardium.
- Emphasizes the importance of assessing for secondary infection foci in bacterial endocarditis cases.