Case Report Giant vegetation in patient with a pacemaker with infective endocarditis

DOI: 10.5935/2318-8219.20190041 Introdução O uso de Dispositivos Cardíacos Implantáveis (DCI), como Marca-Passos (MP), desfibriladores e ressincronizadores, aumentou nas últimas duas décadas e, proporcionalmente, houve incremento das infecções associadas. Os DCI tornaramse sítios frequentes de Endocardite Infecciosa (EI), constituindo problema diagnóstico e terapêutico ainda mais desafiador do que quando a EI ocorre em valvas nativas.1 O diagnóstico de EI pode ser facilmente estabelecido em pacientes com características clássicas. No entanto, na prática clínica, as apresentações atípicas em pacientes com cardiopatias complexas e inúmeras comorbidades levam ao frequente atraso no diagnóstico.2 Na EI em DCI há a limitação do tratamento antimicrobiano exclusivo, sendo necessárias a retirada do dispositivo e a decisão da melhor forma de fazê-lo. O tamanho da vegetação é o parâmetro que sugere a etiologia, a gravidade e a abordagem invasiva. O caso ora relatado surpreende pelo grande tamanho da vegetação encontrada.


Introduction
The use of Implantable Cardiac Devices (ICDs), such as pacemakers, defibrillators and resynchronizers, has increased in the last two decades and, proportionally, there has been an increase in associated infections.ICDs have become frequent sites of infective endocarditis (IE), posing a diagnostic and therapeutic problem that is even more challenging than when IE occurs in native valves. 1 The diagnosis of IE can be easily established in patients with classic characteristics.However, in clinical practice, atypical presentations in patients with complex heart diseases and multiple comorbidities lead to frequent delays in diagnosis. 2In IE in ICD, there is a limitation of exclusive antimicrobial treatment, requiring removal of the device and the decision on the best way to do so.The size of the vegetation is the parameter that suggests the etiology, severity and invasive approach.The case reported here is surprising because of the large size of the vegetation found.

Case report
Female, 63 years old, with PM, admitted with complaints of fever of unknown origin, asthenia, weight loss, petechiae in the upper and lower limbs, progressive dyspnea, cough with hemoptysis and lower limb edema in the past 3 months.Report of urinary infection treatment with clindamycin and metronidazole 15 days before admission.
The patient eventually required hemodialysis.Surgical removal of the PM cord was performed and a no.29 biological valve (Saint Jude Medical, USA) was implanted in the tricuspid position (Video 2).Candida parapsilosis was found in two blood culture samples and initial treatment with micafungin was performed.A fluconazole regimen was instituted for 6 weeks after sensitivity testing.The patient was discharged asymptomatic with improved renal function.Histopathological examination by macroscopy showed irregular tissue segment, measuring 40 × 25 × 20 mm with a brownish base (Figure 2).Microscopic examination showed abundant fibrinoid and leukocyte material.

Discussion
Fungal ICD infections are rare, difficult to suspect, and always lead to delayed diagnosis.Studies have reported that staphylococci (60-80%), Gram-negative bacilli (5 to 12%), polymicrobial infection (2 to 7%) and fungi (2 to 5%) are the main etiologies. 2,3 an echocardiographic study of 60 hospitalized patients with IE associated with ICD, only 19% of the cases with vegetation greater than 20 mm were reported.Of the 60 cases evaluated, 33% had indication of surgical extraction, with mean vegetation size 17.9 ± 7.0 mm, as indicated for our patient.The ICD infection associated with the tricuspid valve was found in this study in only one case. 4e American Heart Association (AHA) guideline recommends complete removal of the device with longterm antibiotic therapy in any patient with device infection.Cord removal can be performed by percutaneous techniques in most cases, but in patients with valve endocarditis or vegetations greater than 30 mm, as in this case, open surgery should be performed. 5Surgery combined with antifungal agents may alter the evolution of the disease.The rate of mortality from IE by Candida sp. has been exceptionally high.It is a rare but often fatal disease.
The rarity of this case is established by the vegetation size of 40 mm, concomitant involvement of the ICD with the valve apparatus, and etiology by Candida sp.