Leonardo Jorge Cordeiro de Paula

Endocarditis Secondary to Microsporidia Giant Vegetation in a Pacemaker User

A 60-year-old white man was admitted with a 2-week history of shivering and fever (38°C). He had had a dual-chamber pacemaker implanted in 1996 because of complete atrioventricular block, with an elective pulse generator replaced 3 months before admission. Medications taken on a daily basis included amiodarone for atrial fibrillation rhythm control and atenolol for hypertension. His blood pressure was normal; his heart rate was 80 bpm; and he was febrile (38.5°C). Chest auscultation revealed a systolic murmur at the left and right sternal borders with respiratory shifting in the heart sound, not previously described in this patient. ECG showed a normally functioning pacemaker (Figure 1). Chest x-ray was normal (Figure 2), as were renal function and differential white cell count. Figure 1. Twelve-lead surface ECG showed a normally functioning dual-chamber pacemaker. Figure 2. A, Frontal anterior-posterior chest x-ray showed a pacemaker in the right infraclavicular region with no other abnormality. B, Normal frontal posterior-anterior chest x-ray after surgical intervention. Endocarditis was confirmed by a transesophageal echocardiography …A 60-year-old white man was admitted with a 2-week history of shivering and fever (38°C). He had had a dual-chamber pacemaker implanted in 1996 because of complete atrioventricular block, with an elective pulse generator replaced 3 months before admission. Medications taken on a daily basis included amiodarone for atrial fibrillation rhythm control and atenolol for hypertension. His blood pressure was normal; his heart rate was 80 bpm; and he was febrile (38.5°C). Chest auscultation revealed a systolic murmur at the left and right sternal borders with respiratory shifting in the heart sound, not previously described in this patient. ECG showed a normally functioning pacemaker (Figure 1). Chest x-ray was normal (Figure 2), as were renal function and differential white cell count. Figure 1. Twelve-lead surface ECG showed a normally functioning dual-chamber pacemaker. Figure 2. A, Frontal anterior-posterior chest x-ray showed a pacemaker in the right infraclavicular region with no other abnormality. B, Normal frontal posterior-anterior chest x-ray after surgical intervention. Endocarditis was confirmed by a transesophageal echocardiography …

Implante de cardio-desfibrilador em gestantes com cardiomiopatia hipertrófica

We describe the successful implantation of a cardioverter-defibrillator (ICD) in two pregnant women with hypertrophic cardiomyopathy at high risk. The indication of ICD and the necessary care for ICD implantation during pregnancy are discussed and were the main objectives of this case report.

Images in cardiovascular medicine. Endocarditis secondary to microsporidia: giant vegetation in a pacemaker user.

A 60-year-old white man was admitted with a 2-week history of shivering and fever (38°C). He had had a dual-chamber pacemaker implanted in 1996 because of complete atrioventricular block, with an elective pulse generator replaced 3 months before admission. Medications taken on a daily basis included amiodarone for atrial fibrillation rhythm control and atenolol for hypertension. His blood pressure was normal; his heart rate was 80 bpm; and he was febrile (38.5°C). Chest auscultation revealed a systolic murmur at the left and right sternal borders with respiratory shifting in the heart sound, not previously described in this patient. ECG showed a normally functioning pacemaker (Figure 1). Chest x-ray was normal (Figure 2), as were renal function and differential white cell count. Figure 1. Twelve-lead surface ECG showed a normally functioning dual-chamber pacemaker. Figure 2. A, Frontal anterior-posterior chest x-ray showed a pacemaker in the right infraclavicular region with no other abnormality. B, Normal frontal posterior-anterior chest x-ray after surgical intervention. Endocarditis was confirmed by a transesophageal echocardiography …A 60-year-old white man was admitted with a 2-week history of shivering and fever (38°C). He had had a dual-chamber pacemaker implanted in 1996 because of complete atrioventricular block, with an elective pulse generator replaced 3 months before admission. Medications taken on a daily basis included amiodarone for atrial fibrillation rhythm control and atenolol for hypertension. His blood pressure was normal; his heart rate was 80 bpm; and he was febrile (38.5°C). Chest auscultation revealed a systolic murmur at the left and right sternal borders with respiratory shifting in the heart sound, not previously described in this patient. ECG showed a normally functioning pacemaker (Figure 1). Chest x-ray was normal (Figure 2), as were renal function and differential white cell count. Figure 1. Twelve-lead surface ECG showed a normally functioning dual-chamber pacemaker. Figure 2. A, Frontal anterior-posterior chest x-ray showed a pacemaker in the right infraclavicular region with no other abnormality. B, Normal frontal posterior-anterior chest x-ray after surgical intervention. Endocarditis was confirmed by a transesophageal echocardiography …

Executive Summary - Guideline on Telecardiology in the Care of Patients with Acute Coronary Syndrome and Other Cardiac Diseases

Cardiology is a very promising field in telemedicine. The transmission of electrocardiograms (ECG) from remote health services or ambulances to a central for analysis is already routine in the approach to acute coronary syndromes (ACS). This approach allows the obtention of expert guidance and referral to appropriate health units, with the potential of saving lives. This impact may be seen in acute myocardial infarction (MI), in which telemedicine has reduced intra-hospital mortality rates from 12.3% to 7.1%1-4.

Response to Letter Regarding Article, “Endocarditis Secondary to Microsporidia: Giant Vegetation in a Pacemaker User”

We appreciate Dr Henrikson’s interest in our study1 and the opportunity to clarify several issues. Dr Henrikson had a very precise observation concerning the electrocardiogram, and we agree with the comments made. Indeed, it was a normofunctioning dual-chamber pacemaker, and the electrocardiogram was taken just before open heart surgery, with the pacemaker programmed to asynchronous ventricular pacing mode considering atrial lead manipulation. Moreover, in our article, we report a novel agent for implantable pacemaker infection in a patient with persistent bacteremia despite the fact that blood cultures were all negative, as highlighted by Dr Henrikson. Most cases of pacemaker lead infections are due to pathogens from the skin flora, with positive blood culture ranging in the literature from 80% to 100% of the cases. Making a parallel with heart valves in the human, there are many causes of culture-negative endocarditis. The causative agents of culture-negative endocarditis in the heart are fastidious bacteria (Bartonella quintana, Coxiella burnetii, or brucella species), fungi, and the usual organisms (mainly streptococci) found in patients who have received antibiotic treatment before blood samples are obtained for culture.2 Thus, we present here another possible etiology in this context, now related to pacemaker infections. While these fastidious bacteria yield negative hemocultures requiring different diagnostic approaches such as serology, in the case of microsporidium, electron microscopy is fundamental and should be complemented by polymerase chain reaction.1 Dr Henrikson also pointed out that no signs of endocarditis were present even though a large vegetation was disclosed. Pacemaker endocarditis may be limited to the pacemaker lead or involve the cardiac valves, generally the tricuspid, which can be demonstrated by the echocardiogram or intraoperatively. In our case there was no vegetation in this valve by both methods, but the mass entailed in valve insufficiency, present in 25% of the cases in one series.3 We cannot rule out that microscopic endocarditis was present because no biopsy specimens were taken from the valve. Nonetheless, the good clinical outcome after a long-term follow-up period makes this possibility unlikely.

Endocarditis Secondary to Microsporidia

A 60-year-old white man was admitted with a 2-week history of shivering and fever (38°C). He had had a dual-chamber pacemaker implanted in 1996 because of complete atrioventricular block, with an elective pulse generator replaced 3 months before admission. Medications taken on a daily basis included amiodarone for atrial fibrillation rhythm control and atenolol for hypertension. His blood pressure was normal; his heart rate was 80 bpm; and he was febrile (38.5°C). Chest auscultation revealed a systolic murmur at the left and right sternal borders with respiratory shifting in the heart sound, not previously described in this patient. ECG showed a normally functioning pacemaker (Figure 1). Chest x-ray was normal (Figure 2), as were renal function and differential white cell count. Figure 1. Twelve-lead surface ECG showed a normally functioning dual-chamber pacemaker. Figure 2. A, Frontal anterior-posterior chest x-ray showed a pacemaker in the right infraclavicular region with no other abnormality. B, Normal frontal posterior-anterior chest x-ray after surgical intervention. Endocarditis was confirmed by a transesophageal echocardiography …A 60-year-old white man was admitted with a 2-week history of shivering and fever (38°C). He had had a dual-chamber pacemaker implanted in 1996 because of complete atrioventricular block, with an elective pulse generator replaced 3 months before admission. Medications taken on a daily basis included amiodarone for atrial fibrillation rhythm control and atenolol for hypertension. His blood pressure was normal; his heart rate was 80 bpm; and he was febrile (38.5°C). Chest auscultation revealed a systolic murmur at the left and right sternal borders with respiratory shifting in the heart sound, not previously described in this patient. ECG showed a normally functioning pacemaker (Figure 1). Chest x-ray was normal (Figure 2), as were renal function and differential white cell count. Figure 1. Twelve-lead surface ECG showed a normally functioning dual-chamber pacemaker. Figure 2. A, Frontal anterior-posterior chest x-ray showed a pacemaker in the right infraclavicular region with no other abnormality. B, Normal frontal posterior-anterior chest x-ray after surgical intervention. Endocarditis was confirmed by a transesophageal echocardiography …

Case 5: 50-year-old woman with restrictive cardiomyopathy, renal failure and proteinuria

Section Edition: Alfredo José Mansur (ajmansur@incor.usp.br) Associated Editors: Desidério Favarato (dclfavarato@incor.usp.br) Vera Demarchi Aiello (anpvera@incor.usp.br) Woman with 50 years of age, born in Pernambuco, coming from São Paulo, sought medical assistance due to dyspnea caused by minor stress. Four months ago, the patient presented signs of dyspnea caused by moderate effort, which 2 month ago progressed to minimum effortand orthopnea. The patient also presented edema on lower limbs. She sought medical assistance, was diagnosed with heart failure and was admitted for treatment. The patient knew she had hypothyroidism for years. During admission, the patient underwent thoracocentesis to drain pleural effusion. The biochemal analysis of the pleural liquid (6 Dec 2007) revealed lactate dehydrogenase (LDH) (pleural effusion/serum) 104/216 = 0.48; protein (pleural effusion/serum) 2.8/6.2 = 0.45; albumin gradient = 1.5. The patient was discharged with prescription of 80 mg of Furosemide, 50 mg of Spironolactone, 75 mg of Captopril, 100 μg of levotiroxin on a daily basis, and 0.25 mg of Digoxin every other day. Her dyspnea showed some improvement, however, some days later the dyspnea worsened again upon effort levels below the usual ones. The patient sought medical assistance in this Hospital. Physical examination (9 Jan 2008) revealed eupneic patient, with increased jugular venous pressure, heart rate at 100 bpm and blood pressure 90 / 80 mm Hg. Lung examination revealed a decreased vesicular murmur on the right hemithorax middle third and abolition on the lower third of both hemithoraxes. Cardiac semiology revealed 4th heart sound, with no murmurs or pericardial friction rub. Her abdomen was painful to percussion in right hyponchondrium region. Her liver was palpated at 10 cm from the right coastal edge; there was edema +++/4+ on lower limbs. Chest radiography (9 Jan 2008) revealed a huge bilateral pleural effusion.

Caso 5: mulher de 50 anos com cardiomiopatia restritiva, insuficiência renal e proteinúria

Section Edition: Alfredo José Mansur (ajmansur@incor.usp.br) Associated Editors: Desidério Favarato (dclfavarato@incor.usp.br) Vera Demarchi Aiello (anpvera@incor.usp.br) Woman with 50 years of age, born in Pernambuco, coming from São Paulo, sought medical assistance due to dyspnea caused by minor stress. Four months ago, the patient presented signs of dyspnea caused by moderate effort, which 2 month ago progressed to minimum effortand orthopnea. The patient also presented edema on lower limbs. She sought medical assistance, was diagnosed with heart failure and was admitted for treatment. The patient knew she had hypothyroidism for years. During admission, the patient underwent thoracocentesis to drain pleural effusion. The biochemal analysis of the pleural liquid (6 Dec 2007) revealed lactate dehydrogenase (LDH) (pleural effusion/serum) 104/216 = 0.48; protein (pleural effusion/serum) 2.8/6.2 = 0.45; albumin gradient = 1.5. The patient was discharged with prescription of 80 mg of Furosemide, 50 mg of Spironolactone, 75 mg of Captopril, 100 μg of levotiroxin on a daily basis, and 0.25 mg of Digoxin every other day. Her dyspnea showed some improvement, however, some days later the dyspnea worsened again upon effort levels below the usual ones. The patient sought medical assistance in this Hospital. Physical examination (9 Jan 2008) revealed eupneic patient, with increased jugular venous pressure, heart rate at 100 bpm and blood pressure 90 / 80 mm Hg. Lung examination revealed a decreased vesicular murmur on the right hemithorax middle third and abolition on the lower third of both hemithoraxes. Cardiac semiology revealed 4th heart sound, with no murmurs or pericardial friction rub. Her abdomen was painful to percussion in right hyponchondrium region. Her liver was palpated at 10 cm from the right coastal edge; there was edema +++/4+ on lower limbs. Chest radiography (9 Jan 2008) revealed a huge bilateral pleural effusion.

Caso 5: mujer de 50 Años con cardiomiopatía restrictiva, insuficiencia renal y proteinuria

Section Edition: Alfredo José Mansur (ajmansur@incor.usp.br) Associated Editors: Desidério Favarato (dclfavarato@incor.usp.br) Vera Demarchi Aiello (anpvera@incor.usp.br) Woman with 50 years of age, born in Pernambuco, coming from São Paulo, sought medical assistance due to dyspnea caused by minor stress. Four months ago, the patient presented signs of dyspnea caused by moderate effort, which 2 month ago progressed to minimum effortand orthopnea. The patient also presented edema on lower limbs. She sought medical assistance, was diagnosed with heart failure and was admitted for treatment. The patient knew she had hypothyroidism for years. During admission, the patient underwent thoracocentesis to drain pleural effusion. The biochemal analysis of the pleural liquid (6 Dec 2007) revealed lactate dehydrogenase (LDH) (pleural effusion/serum) 104/216 = 0.48; protein (pleural effusion/serum) 2.8/6.2 = 0.45; albumin gradient = 1.5. The patient was discharged with prescription of 80 mg of Furosemide, 50 mg of Spironolactone, 75 mg of Captopril, 100 μg of levotiroxin on a daily basis, and 0.25 mg of Digoxin every other day. Her dyspnea showed some improvement, however, some days later the dyspnea worsened again upon effort levels below the usual ones. The patient sought medical assistance in this Hospital. Physical examination (9 Jan 2008) revealed eupneic patient, with increased jugular venous pressure, heart rate at 100 bpm and blood pressure 90 / 80 mm Hg. Lung examination revealed a decreased vesicular murmur on the right hemithorax middle third and abolition on the lower third of both hemithoraxes. Cardiac semiology revealed 4th heart sound, with no murmurs or pericardial friction rub. Her abdomen was painful to percussion in right hyponchondrium region. Her liver was palpated at 10 cm from the right coastal edge; there was edema +++/4+ on lower limbs. Chest radiography (9 Jan 2008) revealed a huge bilateral pleural effusion.