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
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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.
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 2.
Figure 2. Gray exudate on granular epicardial surface consistent with fibrinopurulent pericarditis.
Figure 3.
Figure 3. Photomicrograph (original magnification × 250) of the pericardium with severe inflammation, neutrophilic infiltration and fibrin with entrapped clusters of bacteria.
Figure 4.
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
VariableLabs on admissionReference range
INR: international normalized ratio; HCO3: bicarbonate; BUN: blood urea nitrogen; AST: aspartate aminotransferase; ALT: alanine aminotransferase.
Blood count
  Hemoglobin (g/dL)12.813.7 - 17.5
  White blood cell count (× 103/μL)17.34 - 10
  INR1.30.9 - 1.1
  Sodium (mmol/L)123135 - 145
  Potassium (mmol/L)5.13.5 - 5
  HCO3 (mmol/L)1922 - 31
  BUN (mg/dL)3210 - 20
  Creatinine (mg/dL)1.360.8 - 1.5
  Glucose (mg/dL)15465 - 99
  Lactate (mmol/L)10.30.5 - 2.2
Liver function tests
  Total protein (g/dL)2.30.2 - 1.3
  Albumin (g/dL)1.93.2 - 5.2
  Total Bili (mg/dL)2.30.2 - 1.3
  Alk Phos (unit/L)19940 - 120
  AST (unit/L)670 - 39
  ALT (unit/L)710 - 55
Cardiac markers
  Troponin T (ng/mL)0.1< 0.03
  Creatine kinase (unit/L)890 - 200


Table 2. Infective Endocarditis With Heart Block: Review of the Literature
Case studyNo. of casesAge rangeComorbiditiesOrigin of infectionBacteriologyLocation of abscessValvular involvementHeart block presentOutcome
*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]148SchizophreniaSuspected PNACulture negativeAtrial septumMV/AVCHBDeath
Holt et al, 1979 [5]133Bicuspid AVSuspected PNAStaphylococcus aureusLA with fistula between AV and RAAVCHB (on digoxin)Death
Langaker and Svanes, 1973 [6]176NoneGastroenteritisSalmonella typhimuriumBetween aorta and LA, atrial septumMVCHB (on digoxin)Death
Kopelman et al, 1986 [8]123SLE, Recent AbortionPID, AmniocentesisBacteroidesAortic perivalvular, interventricular septumMV/AV/TVCHBDeath on POD #6 after AVR
Fordyce et al, 2011 [9]172Sciatica, A. FibTransrectal Prostate BiopsyESBL+ E. coliNone found on echoTVCHBSuccessfully treated with antibiotics only
DiNubile et al, 1986 [10]*21112 - 88N/AN/AStrep (50%), Staph (35%), Gram Neg Cocobacilli (5%), Gram Neg Bacilli (3%), fungi (1%)None mentionedAV (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]164Bicuspid AV, severe ASSepsisStaph aureusAortic root abscess tracking into the RV free wall and the ventricular septumAV/TVNoneSuccessfully treated with AVR and TVR
Wang et al, 1972 [12]*14249 - 77Bicuspid AV, prosthetic valveN/AStrep (2%), Staph (1%), E. coli (1%)WBC infiltration of atrial septum and AVN in one patient, cardioaortic fistula in five casesAV (39%)/MV (27%)/AV + MV (20%)CHB (4%) six patients, first Deg or second Deg (10%) 14 patientsDeath in 40%, one successfully treated with AVR
Bacchion et al, 2007 [13]146Bicuspid AV, prosthetic valveDental abscessBacteroides fragilisPerivalvular ring abscess of MVAV/MVFirst Deg and LBBBSuccessfully treated with AVR and MVR
Chu et al, 2006 [14]154Alcoholic cirrhosis, variceal bleed, CKDInfected arteriovenous shuntStaph epidermidisNone found on echoAVCHBDeath
Park et al, 2011 [15]138Bicuspid AV, HTNRecent dental procedureStaph aureusNone found on echoAVFirst DegSuccessfully treated with AVR