Coica Sabina P, Wilson Kyla N, Baroudi Bassam
Cardiology, William Carey University College of Osteopathic Medicine, Hattiesburg, USA.
Internal Medicine, William Carey University College of Osteopathic Medicine, Hattiesburg , USA.
Cureus. 2024 Jul 22;16(7):e65116. doi: 10.7759/cureus.65116. eCollection 2024 Jul.
Blood culture-negative endocarditis (BCNE) poses significant diagnostic and therapeutic challenges and is associated with notable morbidity and mortality. When presented concurrently with other comorbidities, these challenges and the chances of morbidity and mortality significantly increase. This case presents right-sided BCNE accompanied by pulmonary cavitary lesions in a patient with a history of supraventricular tachycardias (SVT), a biventricular pacemaker and implantable cardioverter-defibrillator (BiV-ICD), alcohol use, and anticoagulant noncompliance. The patient missed follow-up appointments for six months after the death of his wife, leading to increased alcohol use and noncompliance with medications. During this period, his home monitoring device was offline. Once reconnected, it detected several episodes of SVT and ventricular tachycardia (VT), prompting a wellness check. He presented to the cardiology clinic with shortness of breath and a cough producing brown-tinged sputum. Evaluation revealed cavitary lesions in the lingula and left lower lobe, a vegetation on his tricuspid valve, and vegetations on his endocardial leads, despite negative blood cultures. Tuberculosis testing was negative, while sputum cultures were positive for Haemophilus influenzae. After ruling out other possible infectious causes of the cavitary lesions, septic emboli were suspected as the cause. Broad-spectrum antibiotics were begun and surgical intervention was done to replace the tricuspid valve and remove the endocardial leads. This procedure was complicated by fibrosis of the leads at the coronary sinus, necessitating their cutting at the superior vena cava and leaving them inside the patient until laser therapy could be performed for their removal. The patient's history of bradycardia and SVTs required the ongoing use of a pacemaker. Inventory discrepancy during the placement of the new pacemaker epicardial leads lead to complications warranting an alternative approach to lead implantation. A traditionally used epicardial lead was placed on the right ventricle for pacing, and an innovative technique was employed to place an endocardial lead on the right atrium epicardium for sensing. This case underscores the importance of thorough evaluation and collaborative management strategies to optimize outcomes for patients with concomitant cardiac and pulmonary pathologies, particularly in the context of underlying psychosocial stressors. Additionally, it demonstrates solutions to challenges that can arise during surgery and presents an alternative lead placement technique for physicians who have only one epicardial lead available after removing infected endocardial leads. This is illustrated by the innovative use of an endocardial lead as an epicardial sensing lead.
血培养阴性的心内膜炎（BCNE）带来了重大的诊断和治疗挑战，且与显著的发病率和死亡率相关。当与其他合并症同时出现时，这些挑战以及发病和死亡的几率会显著增加。本病例呈现了一名患有室上性心动过速（SVT）病史、双心室起搏器和植入式心脏复律除颤器（BiV-ICD）、有饮酒习惯且不依从抗凝治疗的患者发生右侧BCNE并伴有肺空洞性病变。患者在妻子去世后有六个月未进行随访预约，导致饮酒量增加且不依从药物治疗。在此期间，他的家庭监测设备处于离线状态。重新连接后，检测到几次SVT和室性心动过速（VT）发作，促使进行健康检查。他因呼吸急促和咳出褐色痰而就诊于心脏病诊所。评估发现舌叶和左下叶有空洞性病变、三尖瓣上有赘生物以及心内膜导线有赘生物，尽管血培养结果为阴性。结核检测为阴性，而痰培养显示流感嗜血杆菌阳性。在排除空洞性病变的其他可能感染原因后，怀疑是脓毒性栓子所致。开始使用广谱抗生素并进行手术干预，以置换三尖瓣并移除心内膜导线。该手术因冠状窦处导线纤维化而变得复杂，需要在上腔静脉处切断导线并留在患者体内，直到可以进行激光治疗以将其移除。患者的心动过缓和SVT病史需要持续使用起搏器。新的起搏器心外膜导线放置过程中的库存差异导致了并发症，需要采用替代的导线植入方法。将一根传统使用的心外膜导线放置在右心室用于起搏，并采用一种创新技术将一根心内膜导线放置在右心房心外膜用于感知。本病例强调了全面评估和协作管理策略对于优化伴有心脏和肺部疾病患者治疗效果的重要性，特别是在存在潜在心理社会压力源的情况下。此外，它展示了手术过程中可能出现的挑战的解决方案，并为在移除感染的心内膜导线后仅剩下一根心外膜导线的医生提供了一种替代的导线放置技术。这通过将心内膜导线创新性地用作心外膜感知导线得以体现。
