Right-heart endocarditis after pacemaker implantation as a cause of a round pulmonary infiltrate

HISTORY AND CLINICAL FINDINGS: A 57-year-old man developed intermittent fever and fatigue 11 months after a two-chamber cardiac pacemaker had been implanted because of 2 degrees and 3 degrees A-V block. Antituberculosis treatment was initiated as tuberculosis was suspected. The infiltrate regressed, but the other symptoms persisted. Four months later he was admitted as an emergency because of septicaemia. INVESTIGATIONS: In addition to a recently discovered cardiac murmur there was a raised erythrocyte sedimentation rate (116 mm) and leucocytosis (13 600/microliters) with shift to the left. Coagulase-negative staphylococci were grown on several blood cultures. Transoesophageal echocardiography (TOE) demonstrated vegetation on the tricuspid valve, the pacing wires and the right ventricular outflow tract. DIAGNOSIS, TREATMENT AND COURSE: After the diagnosis of infective endocarditis had been established, antibiotic treatment was give with imipenem, gentamycin and teicoplanin, the pacemaker system and adherent thrombotic material were removed and a DDD pacemaker implanted from the other side. The patient remained free of symptoms during a follow-up period of 12 months. INTERPRETATION: Delayed diagnosis of infective endocarditis is not uncommon, because of the scarcity of typical symptoms. Repeated blood cultures and TOE are essential for the diagnosis.