This article reports a case of pacemaker infective endocarditis in a 14 month old girl, caused
by Haemophilus parainfluenzae. There are no other cases in children reported in the
literature. The issues surrounding the case and the evidence which
influenced the management are discussedpeer-reviewe

Kadalraja, R.

Oswal, Neelam

Sammut, Patrick

Woodcock, H.

English

PubMed

OAR@UM

P Sammut, H Woodcock, N Oswal, and R Kadalraja. Pacemaker endocarditis due to Haemophilus parainfluenza: case report and literature review. Images Paediatr Cardiol. 2007 Oct-Dec; 9(4): 15–20.   15  IMAGES  in PAEDIATRIC CARDIOLOGY  Images Paediatr Cardiol. 2007 Oct-Dec; 9(4): 15–20.  PMCID: PMC3232581 Pacemaker endocarditis due to Haemophilus parainfluenza: case report and literature review P Sammut,1 H Woodcock,1 N Oswal,2 and R Kadalraja1 1Department of Paediatrics, Bedford Hospital NHS Trust, Kempston Road, Bedford. MK42 9DJ 2Department of Cardiology, Guy's and St. Thomas' Hospital NHS Trust Contact information: P. Sammut, 10 Southbrooke Close, Trumpington, Cambridge CB2 9HX - UK ; Email: sammutp@nextgen.net.mt Tel: 07792691753 / 01223841919 Copyright : © Images in Paediatric Cardiology This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.  Abstract We report a case of pacemaker infective endocarditis in a 14 month old girl, caused by Haemophilus parainfluenzae. There are no other cases in children reported in the literature. We discuss the issues surrounding the case and the evidence which influenced our management. MeSH: Pacemaker, artificial, Endocarditis, Haemophilus parainfluenzae P Sammut, H Woodcock, N Oswal, and R Kadalraja. Pacemaker endocarditis due to Haemophilus parainfluenza: case report and literature review. Images Paediatr Cardiol. 2007 Oct-Dec; 9(4): 15–20.   16  Introduction We report a 14 month old girl who developed early pacemaker infective endocarditis six weeks after insertion of the pacing device, and briefly discuss investigation and management. There are no other reported cases of paediatric pacemaker infective endocarditis from Haemophilus parainfluenazae in the literature.  Case Report In March 2007 a 14 month old girl with congenital complete heart block underwent implantation of an endocardial pacemaker into the right ventricle. She had remained asymptomatic throughout the first year of life. Six weeks after her pacemaker insertion, she presented with pyrexia, lethargy, diarrhoea, vomiting and poor fluid intake. She was diagnosed with otitis media and sent home on amoxicillin/clavulanic acid. She was seen again two days later as she remained febrile. She was pale and lethargic with a liver edge extending to 1.5cm below the costal margin, and a grade 2/6 systolic murmur. She was sent home and advised to continue her oral antibiotics. Two weeks after initial presentation she became acutely unwell, presenting in shock, with a grade 3/6 systolic murmur. She received a fluid bolus and commenced on intravenous ceftriaxone. CXR showed an enlarged heart with pacemaker and lead in situ (fig 1).  Figure 1 Chest X ray showing cardiomegaly with pacemaker in situ   Investigations showed a C-reactive protein of 275 mg/L, white cell count of 35.7×109/L, neutrophils 17.2×109/L, platelets 111×109/L, and haemoglobin of 7.6g/dl. Infectious endocarditis was suspected. There were no external signs of pacemaker pocket infection. An echocardiogram showed “a mobile mass attached to the pacing P Sammut, H Woodcock, N Oswal, and R Kadalraja. Pacemaker endocarditis due to Haemophilus parainfluenza: case report and literature review. Images Paediatr Cardiol. 2007 Oct-Dec; 9(4): 15–20.   17 wire and tricuspid valve, moderate tricuspid regurgitation and a patent foramen ovale” (fig 2).    Figure 2 2D echocardiography showing mobile vegetation 7.8mm × 9.6mm      Gentamycin was added to the antibiotic regime. Blood cultures showed a pure growth of gram negative rods later confirmed to be Haemophilus parainfluenzae, sensitive to 3rd generation cephalosporins and gentamycin. One week later she underwent open heart surgery under bypass for the complete removal of the infected cardiac pacemaker system (fig. 3). Culture of the vegetation failed to isolate any organisms. A week later she had a permanent epicardial pacemaker system inserted (requiring sternotomy). She was discharged from the cardiothoracic unit two weeks after admission. A follow-up 2D echocardiogram showed moderate tricuspid regurgitation and a small vegetation that was still present near the apical ventricular septum. Clinically she has remained well and haemodynamically stable. P Sammut, H Woodcock, N Oswal, and R Kadalraja. Pacemaker endocarditis due to Haemophilus parainfluenza: case report and literature review. Images Paediatr Cardiol. 2007 Oct-Dec; 9(4): 15–20.   18   Figure 3 Vegetation attached to pacing lead.    Discussion If untreated pacemaker infective endocarditis is fatal. We discuss some management issues surrounding pacemaker endocarditis in children with emphasis on H parainfluenzae. There are few published studies on the epidemiology of pacemaker endocarditis in children. One study by Cohen et al, in a 20 year paediatric cohort, reports an overall incidence of 2.3% of implanted pacemakers.1 Case reports of pacemaker endocarditis from H. parainfluenzae are rare. We conducted a literature search using MEDLINE (1950 to date) and EMBASE (1974 to date) using the key words pacemaker, endocarditis, infection, Haemophilus parainfluenzae. We found only two other case reports of pacemaker endocarditis caused by Haemophilus parainflunzae, and both were in adults (table 1).2,3 Haemophilus parainfluenzae is a commensal of the oral cavity and the upper respiratory tract, and belongs to a group of fastidious gram negative bacilli collectively known as HACEK (Haemophilus spp, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikinella corrodens and Kingella kingae). It is an unusual cause of device related bacterial endocarditis, the majority of which are caused by Staphylococcus aureus and epidermidis. Infective endocarditis in general can present insidiously and time to diagnosis is often prolonged. The commonest presenting feature is fever which is present in 80% of P Sammut, H Woodcock, N Oswal, and R Kadalraja. Pacemaker endocarditis due to Haemophilus parainfluenza: case report and literature review. Images Paediatr Cardiol. 2007 Oct-Dec; 9(4): 15–20.   19 cases.4 Septic shock is the presentation in only 9% of cases.5 When suspected, transthoracic echocardiography (TTE) is an excellent tool for the detection of vegetations in children, with a reported sensitivity of 81%. Transoesophageal echocardiography (TOE) has been shown to have a superior detection rate in adults, but its role in children has yet to be established.  Table 1 Case reports of pacemaker endocarditis caused by Haemophilus parainfluenzae   Strategies to prevent pacemaker endocarditis include primary antibiotic prophylaxis given perioperatively. A meta analysis by De Costa et al was shown to significantly reduce the incidence of serious infective complications following pacemaker insertion.6 Secondary prophylaxis is not routinely recommended, and the American Heart Academy still classifies this group as a negligible risk category. We could not define a clear source of infection in our patient, and can only postulate haematogenous spread from her middle ear infection. Third generation cephalosporins are an excellent choice of antibiotic for HACEK organisms which are often resistant to penicillins. Fluoroquinolones can also be used. However removal of the infected intracardiac device offers the best chance of complete eradication of the infection, with lower morbidity and mortality.7,8 Device re-implantation should be at a new site when the patient is no longer bacteraemic.  Conclusion Pacemaker endocarditis should always be suspected in a child with an implanted pacemaker presenting with fever. Echocardiography is the earliest investigation most likely to confirm the diagnosis. The best treatment is surgical device removal under appropriate antibiotic cover.  References 1. Cohen MI, Bush DM, Gaynor JW, Vetter VL, Tanel RE, Rhodes LA. Pediatric pacemaker infections: twenty years of experience. J Thorac Cardiovasc Surg. 2002;124:821–827. [PubMed: 12324742] 2. Pai RK, Pergam SA, Kedia A, Cadman CS, Osborn LA. Pacemaker lead infection secondary to Haemophilus parainfluenzae. Pacing Clin Electrophysiol. 2004;27:1008–1010. [PubMed: 15271026] P Sammut, H Woodcock, N Oswal, and R Kadalraja. Pacemaker endocarditis due to Haemophilus parainfluenza: case report and literature review. Images Paediatr Cardiol. 2007 Oct-Dec; 9(4): 15–20.   20 3. Rosenbaum GS, Calubiran O, Cunha BA. Haemophilus parainfluenzae bacteremia associated with a pacemaker wire localized by gallium scan. Heart Lung. 1990;19:271–273. [PubMed: 2341266] 4. Baddour LM, Bettmann MA, Bolger AF, Epstein AE, Ferrieri P, Gerber MA, Gewitz MH, Jacobs AK, Levison ME, Newburger JW, Pallasch TJ, Wilson WR, Baltimore RS, Falace DA, Shulman ST, Tani LY, Taubert KA. AHA. Nonvalvular cardiovascular device-related infections. Circulation. 2003;108:2015–2031. [PubMed: 14568887] 5. Hoen B, Alla F, Selton-Suty C, Beguinot I, Bouvet A, Briancon S, Casalta JP, Danchin N, Delahaye F, Etienne J, Le Moing V, Leport C, Mainardi JL, Ruimy R, Vandenesch F. Association pour l’Etude et la Prevention de l’Endocardite Infectieuse (AEPEI) Study Group. Changing profile of infective endocarditis: results of a 1-year survey in France. JAMA. 2002;288:75–81. [PubMed: 12090865] 6. Da Costa A, Kirkorian G, Cucherat M, Delahaye F, Chevalier P, Cerisier A, Isaaz K, Touboul P. Antibiotic prophylaxis for permanent pacemaker implantation: a meta-analysis. Circulation. 1998;97:1796–1780. [PubMed: 9603534] 7. Karchmer AW, Longworth DL. Infections of intracardiac devices. Cardiol Clin. 2003;21:253–271. [PubMed: 12874897] 8. del Rio A, Anguera I, Miro JM, Mont L, Fowler VG, Jr, Azqueta M, Mestres CA. Hospital Clinic Endocarditis Study Group. Surgical treatment of pacemaker and defibrillator lead endocarditis: the impact of electrode lead extraction on outcome. Chest. 2003;124:1451–1459. [PubMed: 14555579]       © Images in Paediatric Cardiology (1999-2012)   

Antibiotic prophylaxis for permanent pacemaker implantation: a metaanalysis.

Association pour l’Etude et la Prevention de l’Endocardite Infectieuse (AEPEI) Study Group. Changing profile of infective endocarditis: results of a 1-year survey in France.

Haemophilus parainfluenzae bacteremia associated with a pacemaker wire localized by gallium scan. Heart Lung.

Hospital Clinic Endocarditis Study Group. Surgical treatment of pacemaker and defibrillator lead endocarditis: the impact of electrode lead extraction on outcome.

Infections of intracardiac devices. Cardiol Clin.

Nonvalvular cardiovascular device-related infections.

Pacemaker lead infection secondary to Haemophilus parainfluenzae. Pacing Clin Electrophysiol.

Pediatric pacemaker infections: twenty years of experience.

Pacemaker endocarditis due to Haemophilus parainfluenza : case report and literature review

https://www.um.edu.mt/library/oar/bitstream/handle/123456789/4105/Pacemaker%20endocarditis%20due%20to%20Haemophilus%20parainfluenza.pdf?sequence=1&isAllowed=y

Pacemaker endocarditis due to Haemophilus parainfluenza : case report and literature review

Abstract

Similar works

Full text

Available Versions

OAR@UM