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(Circulation. 2009;119:2643-2644.)
© 2009 American Heart Association, Inc.

Images in Cardiovascular Medicine

Multisite Vancomycin Intermediate-Sensitive Staphylococcus Aureus Infective Endocarditis With Giant Vegetations on Implantable Cardioverter-Defibrillator Lead

Henry W. Huang, MD; Sherri Pontes, RDCS; Sally B. Slome, MD

From the Permanente Medical Group Inc.

Correspondence to Henry W. Huang, MD, Kaiser Permanente Oakland, 280 W MacArthur Blvd., Oakland, CA 94611. E-mail hwhuang2001@yahoo.com

An extract of the first 250 words of the full text is provided, because this article has no abstract.

A 50-year-old woman was admitted to the hospital with shortness of breath, fever to 102.8°F, and leukocytosis. She had a history of nonischemic cardiomyopathy with ejection fraction of 25% to 35% and prior ventricular fibrillation arrest for which she had received a single-chamber implantable cardioverter-defibrillator about 18 months previously. She also had a history of end-stage renal disease requiring hemodialysis, diabetes mellitus, and hypertension. Over the preceding 5 months, she had experienced recurrent S. aureus dialysis catheter infections with bacteremia, for which she had received intravenous antibiotic therapy, including vancomycin.

On admission to the hospital, ECG showed sinus tachycardia at 108 bpm, left atrial abnormality, and left ventricular hypertrophy with secondary repolarization abnormality (Figure 1). The initial blood cultures grew out methicillin-resistant S. aureus, and she was placed on an intravenous antibiotic regimen of daptomycin and gentamycin. Despite treatment, she continued to have persistently positive blood cultures, fevers, and leukocytosis.

View larger version (86K):   Figure 1. Twelve-lead ECG on admission showed sinus tachycardia at 108 bpm, left atrial abnormality, and left ventricular hypertrophy with secondary repolarization abnormality.

Transesophageal echocardiography was performed to evaluate for evidence of endocarditis. Multiple large vegetations coated the defibrillator lead from the right atrium to the right ventricle (Online-only Data Supplement Movies I and II), with a giant vegetation at the level of the tricuspid valve measuring approximately 2.6x1.8 cm (online-only Data Supplement Movie III). Smaller vegetations involved the native mitral valve, with a coating of bacterial growth seen over the leaflets and annulus, invading . . . [Full Text of this Article]