B49-18 When the Lifeline Turns Lethal: A Rare Case of Pacemaker Lead Wire Endocarditis

Abstract Introduction Pacemaker endocarditis is a rare but life-threatening complication of cardiovascular implantable electronic devices (CIEDs), with reported incidences ranging from 0.13% to 7%. The increasing use of implantable cardiac devices has led to a rise in device-related infections, most commonly caused by Staphylococcus aureus and Staphylococcus epidermidis. Early diagnosis and management are crucial, as delayed recognition carries high morbidity and mortality. Case Presentation A 45-year-old male with a past medical history significant for congenital bradycardia and a cardiac pacemaker in place presented with intractable nausea, vomiting, and diarrhea for two days. He also reported fevers, chills, lightheadedness, and generalized weakness. On arrival to the emergency room, his vitals showed a Tmax of 100.9 °F. Laboratory results revealed sodium 126, potassium 2.8, creatinine 1.4, WBC 12.3 with significant bandemia (24%), platelets 65, and lactic acid 1.3. Chest X-ray showed no acute cardiopulmonary process. CT abdomen and pelvis with contrast demonstrated evidence of fatty liver disease but no splenomegaly. The patient was empirically started on piperacillin-tazobactam along with IV fluid resuscitation. The GI panel was positive for Giardia, for which metronidazole was initiated. The antimicrobial resistance gene test returned positive for Staphylococcus aureus. Blood cultures grew oxacillin-susceptible Staphylococcus aureus, and antibiotics were subsequently changed to daptomycin. Transesophageal echocardiogram revealed a normal left ventricular ejection fraction of 55% with no thrombus noted in the left atrial appendage; however, a vegetation measuring 0.725 × 0.82 cm was observed on the lead wire in the right atrium. Significant aliasing was noted across the tricuspid valve. The patient subsequently underwent laser lead extraction by the electrophysiology team and was managed with cefazolin and ertapenem salvage therapy. Discussion Recognizing pacemaker lead wire endocarditis is often challenging due to its nonspecific and variable clinical presentations, particularly in elderly patients with multiple comorbidities. In this case, our patient was comparatively younger and presented with symptoms suggestive of viral gastroenteritis, which were quite nonspecific. Antibiotic therapy alone is often insufficient due to the high rate of treatment failure and recurrence. This case underscores the critical importance of multimodality imaging in guiding the accurate diagnosis and effective management of pacemaker lead-associated endocarditis. This abstract is funded by: None