Pacemaker lead infection caused by Aspergillus fumigatus

We report a case of pacemaker lead infection caused by Aspergillus fumigatus that was successfully treated by surgery and with voriconazole. This infection is rare and dangerous. When it is suspected, transesophageal echocardiography should be performed to look for lead-attached vegetations and the entire pacing system should be removed.     

Aspergillus fumigatus endocarditis in a patient with a biventricular pacemaker

Aspergillus fumigatus endocarditis is one of the rarest and severest complications in cardiological patients. We describe a patient with an intracardial pacemaker who was diagnosed as having Aspergillus fumigatus endocarditis. Postmortem examination showed a large, Aspergillus-infected thrombus encased in the right ventricle, pulmonary trunk and main pulmonary branches.     

Pacemaker infection due to Aspergillus: report of two cases and literature review

BACKGROUND: Aspergillus infections of pacing systems are extremely uncommon, and most cases reported are characterized by an aggressive behavior that may lead to death of the patient. HYPOTHESIS: The study was undertaken to assess the incidence of pacemaker infection due to Aspergillus in a defined population. METHODS: A retrospective review of the case histories of all patients who underwent pacemaker implantation in the reference center for a defined population over a 13-year period was undertaken. A literature review of pacemaker infections due to Aspergillus was conducted. RESULTS: Of the 1,321 patients who required pacemaker implantation at Hospital Xeral-Calde in the Lugo region of northwestern Spain, 38 suffered a pacemaker infection. A pacemaker pocket infection due to Aspergillus fumigatus was found in two patients. Both patients had a previous history of diabetes mellitus. Cultures from pacemaker pocket inflammatory fluid yielded positive results. Following pacemaker explantation and antifungal therapy, clinical improvement was achieved. A literature review showed another five cases of pacemaker infection due to Aspergillus. However, two peculiarities were found in our patients: In both cases an etiological diagnosis was achieved prior to surgery and, to the best of our knowledge, they also constitute the first cases of pacemaker pocket infection due to Aspergillus. CONCLUSION: Although pacemaker infections due to Aspergillus species are uncommon, they should be considered in immunocompromised patients.     

Aspergillus flavus-infection of a pacemaker wire: continuing evidence for active management of infected pacemakers

A rare case of fungal endocarditis (Aspergillus flavus) on a permanent pacemaker is described. Owing to negative blood culture and non-specific echocardiographic findings, a complete diagnosis was made only on histologic examination of the surgically removed material. In our opinion this case supports an active management of infected pacemakers.     

Pacemaker lead infection: report of three cases and review of the literature

Pacemaker lead infection is a rare condition, most often occurring when intervention is needed after pacemaker implantation. Diagnosis is by blood cultures and confirmation by transoesophageal echocardiography; transthoracic echocardiography is often inadequate. A literature review indicated the microorganism most responsible for late lead infection is Staphylococcus epidermidis (which can grow on plastic material). A retrospective analysis of patient files from the authors' institution (1993-97) yielded three patients with proven pacemaker lead endocarditis. The diagnosis of pacemaker endocarditis was by transoesophageal echocardiography. The endocarditis appeared after a long period and in two of the three patients there was S epidermidis infection. Thoracotomy with removal of the infected system was performed because of the large dimensions of the vegetations. A new pacemaker was implanted: in one patient with endocardial leads, in the other two with epicardial leads. All three patients recovered well and follow up was uneventful for at least one year.     

Pacemaker lead infection: echocardiographic features, management, and outcome

OBJECTIVE: To compare transthoracic and transoesophageal echocardiography (TTE, TOE) in patients with permanent pacemaker lead infection and to evaluate the safety of medical extraction in cases of large vegetations. METHODS: TTE and TOE were performed in 23 patients with definite pacemaker lead infection. Seventeen patients without previous infection served as a TOE reference for non-infected leads. RESULTS: TTE was positive in seven cases (30%) whereas with TOE three different types of vegetations attached to the leads were visualised in 21 of the 23 cases (91%). Of the 20 patients with vegetations and lead culture, 17 (85%) had bacteriologically active infection. Left sided valvar endocarditis was diagnosed in two patients. In the control group, strands were visualised by TOE in five patients, and vegetations in none. Medical extraction of vegetations >/= 10 mm was performed in 12 patients and was successful in nine (75%) without clinical pulmonary embolism. After 31.2 (19.1) months of follow up (mean (SD)), all patients except one were cured of infection; three died from other causes. CONCLUSIONS: Combined with bacteriological data, vegetations seen on TOE strongly suggest pacemaker lead infection. Normal TTE examinations do not exclude this diagnosis because of its poor sensitivity. Medical extraction of even large vegetations appeared to be safe.     

Unusual presentation of papillary fibroelastoma: utility of serial transesophageal echocardiograms

Papillary fibroelastomas are uncommon benign tumors usually involving heart valves that may be potential sources of emboli. Transesophageal echocardiography has greatly enhanced the ability to make the diagnosis of these surgically treatable tumors in a timely fashion. We describe an unusual presentation of a 62-year-old man with suspected bacterial endocarditis, in whom initial transesophageal echocardiogram suggested the presence of pacemaker lead infection but a repeat study after extraction of the pacemaker lead revealed a large pedunculated mass arising from the superior vena cava. The mass was surgically removed and histopathology revealed papillary fibroelastoma. This case is unusual with respect to the size and site of origin of the papillary fibroelastoma as well as its echocardiographic presentation mimicking vegetations on a pacemaker wire.     

Aspergillus endocarditis in association with a false aortic aneurysm

A 32-year-old man was admitted with an intracerebral hematoma and subsequently with bilateral femoral emboli five months after aortic valve replacement. Blood cultures for bacteria and fungi were negative but microscopy of the embolus revealed Aspergillus fumigatus. At operation a large false aneurysm of the ascending aorta and vegetations on the prosthetic aortic valve were found. Aspergillus endocarditis is diagnosed antemortem in only 23% of fatal aortic aneurysms: blood cultures are positive in only 8%. Clinically a large vessel embolus is characteristic, being present in 83% and microscopy and culture of such an embolus if present are vital investigations.     

Prosthetic valve fungal endocarditis due to histoplasmosis

Fungal endocarditis is associated with severe patient morbidity and mortality. Unfortunately, fungal endocarditis is difficult to diagnose because fungal pathogens are uncommonly isolated from routine blood cultures. Histopathological examination of surgically excised cardiac valves, peripheral emboli and systemic ulcers may be useful in identifying pathogens as etiological agents of culture-negative endocarditis. The authors describe a 63-year-old man who had culture-negative endocarditis. Multiple echocardiograms showed progression of the vegetations with valve stenosis despite treatment with multiple antimicrobials. He had multiple peripheral emboli before surgery. Disseminated histoplasmosis was diagnosed by bone marrow culture. Yeast organisms consistent with histoplasma were shown in the vegetations of his excised mitral valve prosthesis. The patient was treated with amphotericin and has been doing well in the two years since his surgery. The diagnosis and management of fungal endocarditis are emphasized.     

Native valve Aspergillus endocarditis in two patients with aplastic anaemia

Native valve fungal endocarditis is an uncommon disease with a high mortality rate. We present the clinical features, histological findings and outcome of 2 patients with native valve Aspergillus endocarditis. Both patients had aplastic anaemia as a predisposing disease. The diagnosis was made by Duke's criteria in 1 case and by histology in the other. Surgery was precluded owing to profound thrombocytopenia. Both patients had fatal outcome despite administration of liposomal amphotericin beta.     

Haemophilus parainfluenzae endocarditis. Two cases and review of the literature in the past decade.

Twenty-five cases of Haemophilus parainfluenzae endocarditis have been reported in the past 10 years, providing a better current perspective of this disease. We have recently diagnosed and treated two patients with H. parainfluenzae endocarditis, and both underwent surgical intervention for complications of their disease. H. parainfluenzae and the other Haemophilus species causing endocarditis often present with a subacute course, often escape early cultural detection and mimic fungal endocarditis in the propensity for large vessel embolization. Multiple emboli and occlusion of major arterial vessels are especially notable features of H. parainfluenzae endocarditis and have occurred in approximately 30 per cent of the cases reported in the past 10 years. In contradistinction to other types of bacterial endocarditis, the most common cause of death in this series has been neurologic complications following embolization.Development of large vegetations appears to be common and may be an intrinsic property of the Haemophilus species, but it is likely that it also reflects the duration of the disease. Delay in recovery of the organism from blood cultures is characteristic of H. parainfluenzae endocarditis and may be due to the strict requirement for V factor exhibited by some strains. Echocardiography has proved useful in suggesting the diagnosis of endocarditis when blood cultures are negative.Optimal antibiotic therapy of H. parainfluenzae endocarditis has not been determined, but the reported clinical experience suggests that combination therapy with ampicillin and an aminoglycoside is the current treatment of choice. Failure to eradicate the organism after a prolonged trial of appropriate antibiotic therapy is not unusual. Indications for surgery in H. parainfluenzae endocarditis may have to be amended to include potential embolization, especially if large vegetations are demonstrated on echocardiography.     

Infective endocarditis following orthotopic heart transplantation: 10 cases and a review of the literature

BACKGROUND: Infective endocarditis is a known complication of cardiac transplantation. However, published information has been limited to case reports and small case series. METHODS: Cardiac transplantation has been performed at Temple University Hospital since 1983. We identified transplant patients with ICD-9 codes for endocarditis or bacteremia. A diagnosis of endocarditis required fulfillment of the Duke criteria and presence of a vegetation. Clinical and microbiologic data were collected. Demographic and survival information were compared with heart transplant recipients without endocarditis. We reviewed all previously published cases using a MEDLINE search. RESULTS: Ten of 659 heart transplant recipients had endocarditis (1.5%, 187 cases per 100,000 person years). Mitral and tricuspid valves were involved predominantly. No patient had aortic valve infection. Patients with tricuspid valve infection had a greater median number of endomyocardial biopsies (n=23) than those with mitral valve infection (n=9, P=0.10). The major pathogens were Staphylococcus aureus (4 cases) and Aspergillus fumigatus (3 cases). Factors associated with S. aureus infection were new hemodialysis catheters, cellulitis, and a contaminated donor organ. All patients with A. fumigatus had antecedent cytomegalovirus viremia and disseminated fungal infection, including endophthalmitis. Endocarditis-related mortality was 80%. Median survival after transplant was 1.4 years in patients with endocarditis, compared with 9.3 years in other heart transplant recipients (P<0.001). CONCLUSIONS: Endocarditis is substantially more common in heart transplant recipients than in general populations. Frequent central venous catheter access and multiple endomyocardial biopsies appear to predispose to infection. Aspergillus is a common pathogen and endocarditis follows infection elsewhere. The prognosis of post-cardiac transplant endocarditis is poor.     

Permanent transvenous pacemaker infections: An analysis of 59 cases

BACKGROUND: Pacemaker infection is a severe process affecting 1-7% of implants. Pulse generator pocket infection is most common. Endocarditis in patients with pacemakers is quite rare. Clinical signs include systemic-related symptoms and severe complications in as many as 40% of cases. The aim of our study was to review our experience and to analyze the epidemiology and treatment of those patients diagnosed as having pacemaker lead endocarditis. METHODS: A retrospective study included all patients diagnosed as having pacemaker endocarditis in our hospital from 1996 to 2002. RESULTS: Fifty-nine patients with pacemaker-related infection were identified, including 39 (66%) with pocket infection. Fever occurred in 25 patients (42%). In 39 patients, a germ was isolated, corresponding to Staphylococcus spp. in 22 (56%). Transthoracic echocardiography demonstrated vegetations in 7 patients (12%), whereas transesophageal echocardiography disclosed abnormal appearances on the pacemaker lead in 10 patients (17%). Ten patients were treated exclusively with antibiotics, while 38 patients required the removal of all infected material. Two patients died. CONCLUSIONS: The diagnosis of endocarditis related to pacemaker infection should be suspected in the presence of fever. High morbidity and mortality are associated with this disease. Prompt treatment, including in some cases removal of the device, is mandatory.     

Pacemaker-related endocarditis: the value of transoesophageal echocardiography in diagnosis and treatment

We report 5 cases with pacemaker endocarditis. All cases were presented with long-standing fever and the diagnosis was confirmed by transoesophageal echocardiography. Besides the contribution to diagnosis, transoesophageal echocardiography defined the technique that was applied to remove the pacing system. In four patients with large vegetations (> 10 mm) the entire pacing system was removed by thoracotomy, while in one with relatively small vegetations (< or = 10 mm) the pacing system was removed by external traction.We have reviewed the literature regarding pacemaker endocarditis, particularly with respect to the role of transoesophageal echocardiography in the early diagnosis and determination of optimal treatment.     

Inhibition of complement by culture supernatants of Aspergillus fumigatus

Aspergillus fumigatus produced a water-soluble extracellular material that inhibited the opsonization of fungal cells by normal human serum. Blastospores of Cryptococcus neoformans and conidia from A. fumigatus or Aspergillus niger were used as fungal targets for ingestion by human monocytes. The opsonic inhibitor from A. fumigatus was found to decrease binding of complement component C3b to fungal surfaces by selectively interfering with activation of the alternative complement pathway. Inhibition of complement did not appear to result simply from proteolysis, as judged by the minimal degradation of casein and of purified C3 and C4. The complement-inhibiting activity was partially labile to heating at 100 C and could be concentrated by using dialysis tubing with a 10,000-dalton exclusion limit. Aspergillus flavus, which is also a pathogen for humans, also produced this activity; A. niger did not. We speculate that this material may represent a pathogenesis factor for Aspergillus species.     

Failure of two-dimensional echocardiography to detect aspergillus endocarditis

Two-dimensional echocardiography has been shown to be a reliable diagnostic procedure in patients with valvular lesions due to fungal endocarditis. We describe a patient with four-chamber Aspergillus endocarditis localized to the nonvalvular endocardium. In this case, two-dimensional echocardiography failed to demonstrate cardiac abnormalities despite the presence of extensive endomyocardial disease at autopsy. The case emphasizes the diagnostic limitations of two-dimensional echocardiography in the absence of valvular vegetations.     

Molecular characterization of aspergillus fumigatus allergens

Aspergillus fumigatus (Af) is ubiquitous saprophytic fungus associated with a broad spectrum of diseases in humans. These diseases range from benign colonization of the lung to life threatening diseases such as allergic bronchopulmonary aspergillosis (ABPA) and invasive aspergillosis. Af is the etiologic agent identified in most of the Aspergillus related human diseases and is therefore of particular clinical importance. Af induced obstructive airway diseases may be due to transient exposure to fungal spores resulting in a T helper 2 response. The IgE mediated inflammatory reaction could be due to colonization of bronchial airway epithelium by Af. Early and precise diagnosis of Aspergillus induced respiratory allergy is essential for preventing irreversible lung damages. The major problems in the diagnosis of A. fumigatus induced diseases are due to the lack of standardized and well characterized fungal extracts. The advent of molecular cloning technology and the development of phage surface display technology for cloning genes have facilitated the isolation of more relevant recombinant allergens. Using these techniques, a panel of different Af allergens having distinct IgE binding with various groups of Af sensitized patients have been cloned and characterized. These allergens can be categorized functionally as secreted and cytoplasmic proteins. The distinct IgE binding property of these purified and well characterized recombinant Af allergens may be useful for the differential diagnosis of Af related pulmonary complications.     

Residual fibrous tissue floating in the right atrium after percutaneous pacemaker lead extraction: an unusual complication early detected by intracardiac echocardiography

Extraction of pacemaker leads represents the optimal therapy in patients with endocarditis involving the pacemaker leads. The percutaneous approach is becoming popular. However, complications of percutaneous extraction are not rare and incomplete removal of the vegetations with embolization in the pulmonary arteries has been described. This case report describes for the first time a case of incomplete removal of the fibrous sheath covering the lead, with residual tissue floating in the right atrium after pacemaker/ICD extraction. ICE monitoring was essential for early detection and correct diagnosis of this complication.     

Experimental pulmonary aspergillosis due to Aspergillus terreus: pathogenesis and treatment of an emerging fungal pathogen resistant to amphotericin B

Aspergillus terreus is an uncommon but emerging fungal pathogen, which causes lethal infections that are often refractory to amphotericin B (AmB). In comparison to Aspergillus fumigatus, A. terreus was resistant to the in vitro fungicidal effects of safely achievable concentrations of AmB. These in vitro findings correlated directly with resistance of A. terreus to AmB in experimental invasive pulmonary aspergillosis. Residual fungal pulmonary burden and galactomannan antigenemia demonstrated persistent infection, despite therapy with deoxycholate AmB or liposomal AmB. By comparison, posaconazole and itraconazole resolved GM antigenemia, reduced residual fungal burden, and improved survival. There were no differences in phagocytic host response to A. terreus versus A. fumigatus; however, the rate of conidial germination of A. terreus was slower. The strain of A. terreus with the highest minimum inhibitory and minimum lethal concentration of AmB also had the lowest membrane ergosterol content. The hyphae of A. terreus in vivo displayed distinctive aleurioconidia, which may be a practical microscopic feature for rapid preliminary diagnosis.     

Clinical Features of Right-sided Infective Endocarditis

METHODSSubjectsWeretrospectivelyinvestigatedpatientswithRIEadmittedinourhospitalfromJan１９８５toDec２０００．Totally１７casesofRIEpatientswereincluded，amongwhich１２male，５female，withageof５to５６（mean２２）yearsold．Allpatientswerediagnosedbasedoncl