MRSE BACTEREMIA VIA PICC LINE WITH AICD LEAD VEGETATION IN A PATIENT WITH HEART FAILURE ON AMBULATORY MILRINONE Elizabeth Long 1 , Sarah C. Forsythe 1 , Chantal Wickman, MD 2 , Jorge A. Martinez, MD, JD 2 ; School of Medicine 1 , Department of Medicine 2 , LSU Health New Orleans, New Orleans, LA.
Introduction: In patients with Peripherally inserted central catheter (PICC) lines, bacteremia occurred in 5.2% of hospitalized patients and 0.5% of outpatients. Electrode lead endocarditis was reported in less than 1% of over 4000 implanted pacemakers and implantable cardio-defibrillators (AICD). Case: A 37-year-old female was transferred from an outside hospital after being treated for 3 to 4 days with fever, chills, nausea, non-bloody emesis, and persistent tachycardia. Past medical history included four-vessel coronary artery disease, requiring a drug eluding stent of the circumflex artery, and postnatal cardiomyopathy; left ventricular ejection fraction was 15%. She had an AICD and had been on Milrinone for four months. Blood cultures at the transferring hospital were positive for methicillin- resistant Staphylococcal epidermidis (MRSE). Blood pressures were 91/55 mmHg, pulse was 92 bpm, and WBC was 14.2K/uL. Chest x-ray and CT suggested infection or neoplasm in the right lower lung. Repeat blood cultures also grew MRSE. Transthoracic echocardiogram showed a large, highly mobile vegetation, about 1cm x 2cm, on one AICD lead. She was maintained on vancomycin. Her PICC line
was exchanged for a midline. Her AICD and leads were removed and a wearable defibrillator was placed. A transesophageal echocardiogram one week later showed no valvular vegetation. Blood cultures at the time of extraction were negative after 5 days. The infiltrate on the chest x-ray was determined to be septic emboli. Before discharge, the midline was exchanged for a double port PICC line for milrinone and four weeks of vancomycin. Discussion: The incidence of lead endocarditis while on long-term inotropes is not widely reported. One study of 200 patients found endocarditis in four patients. However, not all subjects underwent a TEE to evaluate for lead endocarditis. This case demonstrates the need to evaluate for sequelae of bacteremia such as lead endocarditis in patients with implanted devices. Device-related infections increase mortality at five years up to 35%. In bacteremia caused by organisms like MRSE, device and lead removal is recommended. Device retention is associated with a 38% mortality at one year. Evaluation of the possible source of infection, organisms involved, the device, and its leads are essential to reducing recurrence and death.
UNILATERAL PLEURAL EFFUSION IN THE SETTING OF SEVERE MITRAL REGURGITATION Brandon Dang 1 , Alexandra Anderson MD 2 , Sepehr Sadeghi MD2, Brenden Tate 1 ; School of Medicine 1 , Department of Medicine 2 , LSU Health New Orleans, New Orleans, LA.
Introduction: Pleural effusions develop from many pathologies including but not limited to decompensated heart failure, malignancy, pneumonia, and hepatic cirrhosis. The location of the pleural effusion, unilateral or bilateral, can assist in determining the etiology such as how congestive heart failure often presents with bilateral pleural effusions. With that in mind, we present a case of a patient who developed a unilateral, right-sided pleural effusion in the setting of severe mitral regurgitation. Case: A 44-year-old female with HIV, Asthma, systolic heart failure, and recurrent, transudative right-sided pleural effusions presented with dyspnea and bilateral lower extremity edema
that had progressively worsened over the past few months. She was afebrile, with a normal WBC count on presentation. Her most recent CD4 count was 300. Chest x-ray and chest CT demonstrated a large right-sided pleural effusion. Broad spectrum coverage was initially started with azithromycin, doxycycline, ceftriaxone, and trimethoprim-sulfamethoxazole given concern for community-acquired pneumonia or pneumocystis pneumonia. However, she had negative AFB smears, pneumocystis smears, and a negative respiratory panel. Due to her history of recurrent right-sided pleural effusions and effective treatment of fluid overload with diuresis, a trial of Furosemide was given to her with improvements seen in repeat imaging. A prior transthoracic echocardiogram showed
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