The role of transesophageal echocardiography in the diagnosis of polymer-associated infective endocarditis (PIE) in the case of a cardiac stimulator device (CRT-D) with septic arthralgia as the initial manifestation
Dan Cristian Briscan1
1Oradea University of Medicine and Pharmacy, Doctoral School of Biomedical Sciences, Oradea, Romania
Infective endocarditis (IE) represents the microbial colonization of the native structures of the cardiac valve or a heterogeneous intracardiac implanted material, in our case, a probe endocarditis as part of a polymer-associated endocarditis (PIE). Sepsis is the most common syndrome seen in the intensive care unit. An underlying infection of infective endocarditis should be early included in the differential diagnosis, because this can significantly affect the patient’s prognosis. Often, fever occurs on multimorbid patients with corresponding predisposing factors, such as patients with prosthetic cardiac implants, with pacemaker implants or with implantable cardioverter defibrillators, patients after a hemodialysis catheter implant or after the placement of the central venous catheter. Infective endocarditis can be easily ignored in case of urosepsis associated with a nephroureteral drain catheter or in case of cholecystitis with cholecystolithiasis. A detailed anamnesis cannot be made on a patient with sepsis, dementia or drug abuse. The anamnesis made by interviewing other persons can also be insufficient if, for example, the patient lives alone or in a nursing home. In case fever of unknown origin appears associated with recurrence or an aggravated heart murmur, dyspnea on exertion or on rest, headache, general fatigue, weight loss, appetite loss, night sweats, myalgia or arthralgia with/without other symptoms such as Janeway lesions, Osler nodes, splinter hemorrhages, the family doctor must refer the patient to the hospital for subsequent explanations, i.e. for diagnosis.
In case of negative results when searching for the so-called infection outbreak, respectively in case of recurrent fever/ sepsis, the differential diagnosis of infective endocarditis in an early stage must be considered. Additionally, an interdisciplinary co-assessment should be made by the dentist, the urologist and the gynecologist. The gold standard of the microbiological diagnosis of sepsis reveals bacteremia in the context of infective endocarditis with typical pathogens in blood cultures. However, in case of suspicion of infective endocarditis or of a genesis associated with a catheter, besides more blood culture pairs drawn through peripheral venepuncture, a blood culture from the central venous catheter (CVC) must be also drawn. Additionally, as part of the gold standard in the diagnosis of infective endocarditis, the detection of a cardiac lesion of the endocardium using transesophageal echocardiography (TEE) as the main method, except involving the tricuspid valve, when using the transthoracic echocardiography (TTE) makes it more obvious. The diagnostic assistance is provided through the Duke criteria.
The gold standard for the treatment of infective endocarditis is 4 weeks of intravenous antibiotic therapy or, if it involves a polymer material or if associated with a catheter, it means 6 weeks of intravenous antibiotic therapy. If making a diagnosis or determining a therapy becomes difficult, one should quickly accept the help given by a higher competence center. According to the indications given by the specialized team, an early surgical intervention for surgical rehabilitation seems to be a favorable prognosis and it can improve both the therapy and the prognosis. In polymer or catheter-associated endocarditis, the immediate and complete removal of the entire polymer material, the entire implant and the catheter, represents a therapeutic standard. By examining the coronary angioplasty, one can additionally distinguish a deposit of contrast media on the infected heart valve prosthesis in case of infective endocarditis. If bacteremia of unknown origin, fever and the joint pain occur, one must take into consideration infective endocarditis as part of the differential diagnosis and make the right diagnosis in order to exclude it.