Transvenous Pacemaker Lead Removal in Pacemaker Lead Endocarditis with Large Vegetations: A Report of Two Cases
A 63-year-old male was admitted for fever and confusion of three days. He had undergone pacemaker (VDD type) implantation for symptomatic sick sinus syndrome three months prior.\nUpon admission, the patient was febrile with a temperature of 38.3℃, confused and had dysarthric speech. Physical examination was remarkable for warmth, erythema, and tenderness of the skin overlying the pacemaker pocket, which was exposed. His white blood cell (WBC) count was 18.40×103/µL, and C-reactive protein (CRP) concentration was 148.27 mg/L. Transthoracic echocardiogram (TTE) revealed vegetations attached to the tricuspid valve (2.4×1.1 cm) (, arrow), right atrium (0.8×0.8 cm) (, broken arrow), and mitral valve (0.7×0.5 cm) (, arrow). Brain magnetic resonance imaging results were consistent with multiple acute embolic infarcts (). Computed tomography scan of the chest and abdomen showed multiple cavitary nodules in both lungs () and small, low-attenuated lesions in segment 6 of the liver (), suggesting septic embolism.\nOn the same day, the patient underwent transvenous removal of the pacemaker lead (). Pocket site swab cultures and three separate sets of blood cultures were collected and later revealed methicillin-resistant, Staphylococcus aureus. The patient was treated with vancomycin 1000 mg every 12 hours. On the tenth day, blood cultures were negative for the first time. The patient's fever relapsed at day 14 and three of three blood cultures grew Candida tropicalis (C. tropicalis). Repeated blood cultures were positive for C. tropicalis until day 18. Antifungal treatment was started intravenously and continued for a total of six weeks, including four weeks with liposomal amphotericin B 350 mg/day (5 mg/kg) and two weeks with fluconazole 400 mg/day. After 22 days, vegetations of tricuspid valve and right atrium were no longer visible on TTE (). The patient was discharged after eight weeks of admission and no relapse was documented at the six months clinical visit.