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  Table of Contents    
LETTER TO EDITOR  
Year : 2017  |  Volume : 60  |  Issue : 3  |  Page : 441-442
Pacemaker lead infective endocarditis in immunocompetent host due to Aspergillus: An uncommon occurrence


1 Department of Pathology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
2 Department of Cardiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

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Date of Web Publication22-Sep-2017
 

How to cite this article:
Singh A, Goyal A, Singh B, Sood N. Pacemaker lead infective endocarditis in immunocompetent host due to Aspergillus: An uncommon occurrence. Indian J Pathol Microbiol 2017;60:441-2

How to cite this URL:
Singh A, Goyal A, Singh B, Sood N. Pacemaker lead infective endocarditis in immunocompetent host due to Aspergillus: An uncommon occurrence. Indian J Pathol Microbiol [serial online] 2017 [cited 2019 Dec 9];60:441-2. Available from: http://www.ijpmonline.org/text.asp?2017/60/3/441/215367


Editor,

Aspergillus infections of pacemaker leads are extremely uncommon. The most cases reported are characterized by an aggressive behavior in immunocompromised patients with high mortality.[1] Many risk factors have been associated with the invasive aspergillosis, including diabetes mellitus, transplantation, leukopenia, drug therapy like use of corticosteroids and immunosuppressive.[2] We report the first case to our knowledge about rare occurrence of pacemaker lead infection in an immunocompetent host.

A known hypertensive 50-year-old patient had undergone permanent pacemaker implantation in 2011 due to syncope and trifascicular block. At that time, an implantable high impedance permanent pacing lead was inserted in right ventricular apex through right subclavian vein and thus single chamber multiprogrammable pacemaker was installed. Right atrial pole was placed in right atria, and pulse generator was placed in the right infraclavicular fossa. Now he presented in March 2015 with fever and breathlessness of 2 weeks duration. Two-dimensional echocardiography showed concentric left ventricular hypertrophy with some mobile structure seen in right atrium attached to pacing lead? vegetation. Moderate tricuspid regurgitation (TR) was noted with pulmonary artery systolic pressure (PASP) of 35 mmHg. Ejection fraction was 60%. Three-dimensional transesophageal echocardiography was done which showed large round-shaped multiple mobile masses of size 4.5 cm × 6.5 cm attached to pacing lead and oscillating across tricuspid valve; echo density was comparable to the endocardium. At superior vena cava, level small echogenic masses were also noted. PASP was 40 mm of Hg. Thus, the diagnosis of infective endocarditis with TR and pacing lead vegetation was made. Ultrasound showed mild bilateral pleural effusion with fatty liver and increased echogenicity of both kidneys with diminished corticomedullary differentiation. His viral markers were nonreactive. Serum procalcitonin levels were 11.86 ng/ml indicating severe sepsis. Aspergillus galactomannan antigen value was 4.09-significantly positive (<0.5 = negative) suggesting invasive fungal infection. Total leukocyte count was 16.8 × 109/L with neutrophilia and eosinophilia. Hemoglobin was 9.8 g/dl, platelet count: 295 × 103/ul, Partial Thromboplastin Time Activated with Kaolin (PTTK): 37.8 s, urea: 333 mg/dl, creatinine: 7.19 followed by 5.72 mg/dl after a day. He was not a known diabetic with HbA1C levels were 6.2%. Liver and renal function tests (LFTs & RFTs) were in normal range. Urine and blood culture showed no growth of any pyogenic organisms. Suction tip on Gram-staining show no Gram-positive organisms, but culture showed the presence of  Escherichia More Details coli showing sensitivity to amikacin. Bilateral lower limb venous Doppler was normal. Malaria antigen, leptospira IgM, and H1N1 were negative. His fever was persisting near to 100°F. Underwent hemodialysis because of deranged RFT's. His pacemaker leads were removed and sent for histopathology examination and also for culture and sensitivity.

On Gross examination, there was multiple grayish white masses adherent to both atrial and ventricular pacing leads, the largest one measuring 7 cm × 3 cm in size. The outer surface was smooth and glistening while cut section and inner surface was rough and was showing projections [Figure 1]a and [Figure 1]b. Microscopy showed granulomatous inflammation with giant cell reaction with a large area of necrosis [Figure 1]c. Large masses of septate fungal hyphae with acute angle branching were seen [Figure 1]d. Eosinophilia observed in our patient is probably allergic reaction to Aspergillus infection. Peripheral blood eosinophil count markedly decreased after the removal of infected leads.
Figure 1: (a and b) Gross specimen of infected leads showing large fungal masses. (c) Microscopy revealed foreign body giant cell reaction against fungus with inflammatory granulation (H and E, ×400). (d) Acute angled branching septate hyphae of Aspergillus (GMS, ×400)

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Usual culprit fungal organisms are Candida albicans and Aspergillus species.[3] Diagnosis of pacemaker lead infection could be difficult, however transesophageal echocardiography could be crucial in diagnosis by visualizing pacing lead vegetation. Antifungal therapy alone is rarely successful, and thus infected leads must be removed for optimal management. Pacemaker endocarditis is not common but if occurs threaten the patient's life. Infection associated with these permanently indwelling intravascular prostheses may occur without any local evidence of inflammation. However, most disseminated infection due to Aspergillus species has been reported only in patients with a compromised host defense system.[4] Izquierdo et al.[5] described two immunocompromised and diabetic cases with pacemaker pocket infection due to Aspergillus fumigatus. However, our case was neither diabetic nor immunocompromised. The patient was put on amphotericin B but died after few days.

Surgeons, cardiologists, and pathologists should aware that Aspergillus can cause both early and late pacemaker infection and also in both immunocompromised and immunocompetent hosts. Overall survival of fungal endocarditis is very poor. Early diagnosis is very crucial to proper management. Successful treatment is based on the administration of antifungal agents for a longer period and also early surgical intervention. However, in spite of best efforts this fungal infection can kill with poor outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Kramer L, Rojas-Corona RR, Sheff D, Eisenberg ES. Disseminated aspergillosis and pacemaker endocarditis. Pacing Clin Electrophysiol 1985;8:225-9.  Back to cited text no. 1
    
2.
Escribano Subías P, López Ríos F, Delgado Jiménez JF, Sotelo Rodríguez T, Aguado JM, Rodríguez Hernández E. Mycotic aneurysm caused by Aspergillus of the aortic suture line after heart transplantation. Rev Esp Cardiol 2000;53:1403-5.  Back to cited text no. 2
    
3.
Mylonakis E, Calderwood SB. Infective endocarditis in adults. N Engl J Med 2001;345:1318-30.  Back to cited text no. 3
    
4.
Kim HY, Kim CJ, Rho TH, Youn HJ, Cho EJ, Jin SW, et al. Aspergillus infection in a large thrombus of a permanent ventricular pacing lead. J Korean Med Sci 2002;17:691-4.  Back to cited text no. 4
    
5.
Izquierdo R, Llorente C, Mayo J, Garcia-Porrua C, Gonzalez-Juanatey C, Gonzalez-Gay MA. Pacemaker infection due to Aspergillus: Report of two cases and literature review. Clin Cardiol 2005;28:36-8.  Back to cited text no. 5
    

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Correspondence Address:
Aminder Singh
Department of Pathology, Dayanand Medical College and Hospital, Tagore Nagar, Ludhiana - 141 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_257_16

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