Right-heart endocarditis after pacemaker implantation as a cause of a round pulmonary infiltrate

A 57-year-old man developed intermittent fever and fatigue 11 months after a two-chamber cardiac pacemaker had been implanted because of 2 degrees and 3 degrees A-V block. Antituberculosis treatment was initiated as tuberculosis was suspected. The infiltrate regressed, but the other symptoms persisted. Four months later he was admitted as an emergency because of septicaemia. In addition to a recently discovered cardiac murmur there was a raised erythrocyte sedimentation rate (116 mm) and leucocytosis (13 600/microliters) with shift to the left. Coagulase-negative staphylococci were grown on several blood cultures. Transoesophageal echocardiography (TOE) demonstrated vegetation on the tricuspid valve, the pacing wires and the right ventricular outflow tract. After the diagnosis of infective endocarditis had been established, antibiotic treatment was give with imipenem, gentamycin and teicoplanin, the pacemaker system and adherent thrombotic material were removed and a DDD pacemaker implanted from the other side. The patient remained free of symptoms during a follow-up period of 12 months. Delayed diagnosis of infective endocarditis is not uncommon, because of the scarcity of typical symptoms. Repeated blood cultures and TOE are essential for the diagnosis.