J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website http://www.jocmr.org

Case Report

Volume 7, Number 11, November 2015, pages 890-895

Infective Endocarditis Presenting as Complete Heart Block With an Unexpected Finding of a Cardiac Abscess and Purulent Pericarditis

Figure 1. EKG in emergency room showing complete heart block with junctional escape at 48 bpm, Q waves in V1-V2 and diffuse ST segment elevations.

Figure 3. Photomicrograph (original magnification × 250) of the pericardium with severe inflammation, neutrophilic infiltration and fibrin with entrapped clusters of bacteria.

Figure 4. Gross view of the heart showing the abscess in the atrial septal wall (arrow). LV: left ventricle. LA: left atrium.

**Table 1.** Pertinent Laboratory Data
Variable	Labs on admission	Reference range
INR: international normalized ratio; HCO₃: bicarbonate; BUN: blood urea nitrogen; AST: aspartate aminotransferase; ALT: alanine aminotransferase.
Blood count
Hemoglobin (g/dL)	12.8	13.7 - 17.5
White blood cell count (× 10³/μL)	17.3	4 - 10
INR	1.3	0.9 - 1.1
Chemistry
Sodium (mmol/L)	123	135 - 145
Potassium (mmol/L)	5.1	3.5 - 5
HCO₃ (mmol/L)	19	22 - 31
BUN (mg/dL)	32	10 - 20
Creatinine (mg/dL)	1.36	0.8 - 1.5
Glucose (mg/dL)	154	65 - 99
Lactate (mmol/L)	10.3	0.5 - 2.2
Liver function tests
Total protein (g/dL)	2.3	0.2 - 1.3
Albumin (g/dL)	1.9	3.2 - 5.2
Total Bili (mg/dL)	2.3	0.2 - 1.3
Alk Phos (unit/L)	199	40 - 120
AST (unit/L)	67	0 - 39
ALT (unit/L)	71	0 - 55
Cardiac markers
Troponin T (ng/mL)	0.1	< 0.03
Creatine kinase (unit/L)	89	0 - 200

Table 1. Pertinent Laboratory Data

Variable

Labs on admission

Reference range

INR: international normalized ratio; HCO₃: bicarbonate; BUN: blood urea nitrogen; AST: aspartate aminotransferase; ALT: alanine aminotransferase.

Blood count

Hemoglobin (g/dL)

12.8

13.7 - 17.5

White blood cell count (× 10³/μL)

17.3

4 - 10

INR

1.3

0.9 - 1.1

Chemistry

Sodium (mmol/L)

123

135 - 145

Potassium (mmol/L)

5.1

3.5 - 5

HCO₃ (mmol/L)

22 - 31

BUN (mg/dL)

10 - 20

Creatinine (mg/dL)

1.36

0.8 - 1.5

Glucose (mg/dL)

154

65 - 99

Lactate (mmol/L)

10.3

0.5 - 2.2

Liver function tests

Total protein (g/dL)

2.3

0.2 - 1.3

Albumin (g/dL)

1.9

3.2 - 5.2

Total Bili (mg/dL)

2.3

0.2 - 1.3

Alk Phos (unit/L)

199

40 - 120

AST (unit/L)

0 - 39

ALT (unit/L)

0 - 55

Cardiac markers

Troponin T (ng/mL)

0.1

< 0.03

Creatine kinase (unit/L)

0 - 200

**Table 2.** Infective Endocarditis With Heart Block: Review of the Literature
Case study	No. of cases	Age range	Comorbidities	Origin of infection	Bacteriology	Location of abscess	Valvular involvement	Heart block present	Outcome
*Noteworthy studies. AV: aortic valve; MV: mitral valve; TV: tricuspid valve; LA: left atrium; RA: right atrium; CHB: complete heart block; BBB: bundle branch block; AS: aortic stenosis; SLE: systemic lupus erythematosus; CKD: chronic kidney disease; PNA: pneumonia; AVN: atrioventricular node; AVR: aortic valve replacement; PID: pelvic inflammatory disease; POD: post-operative day; CHF: congestive heart failure; HTN: hypertension; A. Fib: atrial fibrillation; N/A: not applicable (missing data).
Zettner and Irmiere, 1959 [4]	1	48	Schizophrenia	Suspected PNA	Culture negative	Atrial septum	MV/AV	CHB	Death
Holt et al, 1979 [5]	1	33	Bicuspid AV	Suspected PNA	Staphylococcus aureus	LA with fistula between AV and RA	AV	CHB (on digoxin)	Death
Langaker and Svanes, 1973 [6]	1	76	None	Gastroenteritis	Salmonella typhimurium	Between aorta and LA, atrial septum	MV	CHB (on digoxin)	Death
Kopelman et al, 1986 [8]	1	23	SLE, Recent Abortion	PID, Amniocentesis	Bacteroides	Aortic perivalvular, interventricular septum	MV/AV/TV	CHB	Death on POD #6 after AVR
Fordyce et al, 2011 [9]	1	72	Sciatica, A. Fib	Transrectal Prostate Biopsy	ESBL+ E. coli	None found on echo	TV	CHB	Successfully treated with antibiotics only
DiNubile et al, 1986 [10]*	211	12 - 88	N/A	N/A	Strep (50%), Staph (35%), Gram Neg Cocobacilli (5%), Gram Neg Bacilli (3%), fungi (1%)	None mentioned	AV (36%)/MV (33%)/TV (5%)	First Deg (45%), second Deg (15%), CHB (20%)	Death in 20% (43 cases), CHF in 7% of patients
Landi et al, 2009 [11]	1	64	Bicuspid AV, severe AS	Sepsis	Staph aureus	Aortic root abscess tracking into the RV free wall and the ventricular septum	AV/TV	None	Successfully treated with AVR and TVR
Wang et al, 1972 [12]*	142	49 - 77	Bicuspid AV, prosthetic valve	N/A	Strep (2%), Staph (1%), E. coli (1%)	WBC infiltration of atrial septum and AVN in one patient, cardioaortic fistula in five cases	AV (39%)/MV (27%)/AV + MV (20%)	CHB (4%) six patients, first Deg or second Deg (10%) 14 patients	Death in 40%, one successfully treated with AVR
Bacchion et al, 2007 [13]	1	46	Bicuspid AV, prosthetic valve	Dental abscess	Bacteroides fragilis	Perivalvular ring abscess of MV	AV/MV	First Deg and LBBB	Successfully treated with AVR and MVR
Chu et al, 2006 [14]	1	54	Alcoholic cirrhosis, variceal bleed, CKD	Infected arteriovenous shunt	Staph epidermidis	None found on echo	AV	CHB	Death
Park et al, 2011 [15]	1	38	Bicuspid AV, HTN	Recent dental procedure	Staph aureus	None found on echo	AV	First Deg	Successfully treated with AVR

Table 2. Infective Endocarditis With Heart Block: Review of the Literature

Case study

No. of cases

Age range

Comorbidities

Origin of infection

Bacteriology

Location of abscess

Valvular involvement

Heart block present

Outcome

*Noteworthy studies. AV: aortic valve; MV: mitral valve; TV: tricuspid valve; LA: left atrium; RA: right atrium; CHB: complete heart block; BBB: bundle branch block; AS: aortic stenosis; SLE: systemic lupus erythematosus; CKD: chronic kidney disease; PNA: pneumonia; AVN: atrioventricular node; AVR: aortic valve replacement; PID: pelvic inflammatory disease; POD: post-operative day; CHF: congestive heart failure; HTN: hypertension; A. Fib: atrial fibrillation; N/A: not applicable (missing data).

Zettner and Irmiere, 1959 [4]

Schizophrenia

Suspected PNA

Culture negative

Atrial septum

MV/AV

CHB

Death

Holt et al, 1979 [5]

Bicuspid AV

Suspected PNA

Staphylococcus aureus

LA with fistula between AV and RA

CHB (on digoxin)

Death

Langaker and Svanes, 1973 [6]

None

Gastroenteritis

Salmonella typhimurium

Between aorta and LA, atrial septum

CHB (on digoxin)

Death

Kopelman et al, 1986 [8]

SLE, Recent Abortion

PID, Amniocentesis

Bacteroides

Aortic perivalvular, interventricular septum

MV/AV/TV

CHB

Death on POD #6 after AVR

Fordyce et al, 2011 [9]

Sciatica, A. Fib

Transrectal Prostate Biopsy

ESBL+ E. coli

None found on echo

CHB

Successfully treated with antibiotics only

DiNubile et al, 1986 [10]*

211

12 - 88

N/A

Strep (50%), Staph (35%), Gram Neg Cocobacilli (5%), Gram Neg Bacilli (3%), fungi (1%)

None mentioned

AV (36%)/MV (33%)/TV (5%)

First Deg (45%), second Deg (15%), CHB (20%)

Death in 20% (43 cases), CHF in 7% of patients

Landi et al, 2009 [11]

Bicuspid AV, severe AS

Sepsis

Staph aureus

Aortic root abscess tracking into the RV free wall and the ventricular septum

AV/TV

None

Successfully treated with AVR and TVR

Wang et al, 1972 [12]*

142

49 - 77

Bicuspid AV, prosthetic valve

N/A

Strep (2%), Staph (1%), E. coli (1%)

WBC infiltration of atrial septum and AVN in one patient, cardioaortic fistula in five cases

AV (39%)/MV (27%)/AV + MV (20%)

CHB (4%) six patients, first Deg or second Deg (10%) 14 patients

Death in 40%, one successfully treated with AVR

Bacchion et al, 2007 [13]

Bicuspid AV, prosthetic valve

Dental abscess

Bacteroides fragilis

Perivalvular ring abscess of MV

AV/MV

First Deg and LBBB

Successfully treated with AVR and MVR

Chu et al, 2006 [14]

Alcoholic cirrhosis, variceal bleed, CKD

Infected arteriovenous shunt

Staph epidermidis

None found on echo

CHB

Death

Park et al, 2011 [15]

Bicuspid AV, HTN

Recent dental procedure

Staph aureus

None found on echo

First Deg

Successfully treated with AVR