Systemic infection due to subcutaneous implantable cardioverter-defibrillator implantation: Importance of early recognition and treatment of device pocket-related complications

Rare Proteus mirabilis Aortic Valve Infective Endocarditis without a Urinary Tract Infection

Proteus mirabilis infective endocarditis is a rare disease with only 17 reported cases. It is typically associated with urinary tract infections (UTIs), staghorn calculi, and/or asymptomatic bacteriuria. We present a case of a 73-year-old male who presented with positive blood cultures for Proteus mirabilis but with a negative urinalysis and urine culture. He presented with acute renal failure and required hemodialysis. TTE was remarkable for a 30% ejection fraction, and no vegetations were visualized. TEE demonstrated a small vegetation on the left aortic valve. The initial urine culture remained negative throughout his hospitalization. He was treated with IV antibiotics and discharged without hemodialysis.

TOXOPLASMOSIS RETINOCHOROIDITIS MASQUERADING AS ENDOGENOUS ENDOPHTHALMITIS IN A CASE OF CONGENITAL LONG QT SYNDROME

PURPOSE

To describe the diagnostic and treatment challenges of a case of presumed acquired macula-involving toxoplasmosis retinochoroiditis.

METHODS

Case report of a woman with congenital long QT syndrome presenting with retinochoroiditis after undergoing a cardiac procedure. Laboratory analysis, ocular fluid biopsy, and multimodal imaging were obtained.

RESULTS

Ophthalmic examination was significant for decreased vision and a macula-involving chorioretinal lesion concerning for endogenous endophthalmitis. Multimodal imaging showed a focal, full-thickness necrotizing process associated with vitritis, retinal edema, and choroidal thickening. Analysis of peripheral blood revealed elevated serum toxoplasma Immunoglobulin G titers. Blood cultures and a transesophageal echocardiogram were negative for endocarditis. Aqueous and vitreous specimens were negative for an infectious polymerase chain reaction panel, including toxoplasmosis and negative bacterial and fungal cultures. A diagnosis of presumed acquired toxoplasmosis retinochoroiditis was made and treated with a combination of oral and intravitreal antiparasitic medications resulting in healing of the retinochoroiditis.

CONCLUSION

To the authors' knowledge, this is the first reported case of acquired toxoplasmosis retinochoroiditis in an immunocompetent patient with congenital long QT syndrome masquerading as endogenous endophthalmitis. The association of congenital long QT syndrome and a recent cardiac procedure with a risk for endogenous endophthalmitis complicated the diagnosis, clinical course, and treatment options. Our case emphasizes the importance of a thorough patient history, comprehensive clinical examination, and supportive multimodal imaging that were used to characterize the infectious process and guide empirical treatment. In addition, laboratory analysis, comanagement with other specialists, and evaluating the response to antitoxoplasma therapy were all instrumental in the eventual diagnosis and treatment of ocular toxoplasmosis in this atypical case.

Diagnosis and management of subcutaneous implantable cardioverter-defibrillator infections based on process mapping

BACKGROUND

Infection is a well-recognized complication of cardiovascular implantable electronic device (CIED) implantation, including the more recently available subcutaneous implantable cardioverter-defibrillator (S-ICD). Although the AHA/ACC/HRS guidelines include recommendations for S-ICD use, currently there are no clinical trial data that address the diagnosis and management of S-ICD infections. Therefore, an expert panel was convened to develop consensus on these topics.

METHODS

A process mapping methodology was used to achieve a primary goal - the development of consensus on the diagnosis and management of S-ICD infections. Two face-to-face meetings of panel experts were conducted to recommend useful information to clinicians in individual patient management of S-ICD infections.

RESULTS

Panel consensus of a stepwise approach in the diagnosis and management was developed to provide guidance in individual patient management.

CONCLUSION

Achieving expert panel consensus by process mapping methodology in S-ICD infection diagnosis and management was attainable, and the results should be helpful in individual patient management.

Strategies to Prevent Cardiac Implantable Electronic Device Infection

The association between the risk of mortality and cardiovascular implantable electronic device (CIED) infections has been well-established in the literature. As CIED implantations have increased in frequency in the past few decades, the incidence of CIED-related infections has also risen. Given the morbidity, mortality, and health-care costs associated with CIED infections, the prevention of device-related infection is a critical goal. Risk factors for developing CIED infections can be categorized as patient-, procedure-, or device-related. Numerous studies have highlighted different strategies for preventing CIED-related infections, which include patient optimization, device selection, and periprocedural preparation and treatment. Nonetheless, as the comorbidity burden of patients undergoing CIED implantation continues to increase, significant challenges in the successful elimination of CIED-related infections remain. This review provides a comprehensive overview of available evidence-based approaches and strategies to reduce the risk of CIED infections.