A 69‐year‐old man with a medical history of coronary artery disease, ischemic cardiomyopathy, and heart block status post pacemaker (PPM) with AICD placement presented to the emergency department (ED) with complaints of fevers and bilateral shoulder and hip pains for 2 days. The pain was most severe in the left shoulder. On arrival in the ED, the patient had a temperature of 103°F. On exam, the patient had no joint swelling or erythema, but did have decreased range of motion due to pain. White blood cell count was 12.8. Chest x‐ray showed no infiltrate and urinalysis was negative for infection. EKG (Fig. 1) showed ventricular pacing with a wide QRS complex. The patient was admitted to the medicine service and monitored off antibiotics. The following day, blood cultures grew out gram positive cocci in clusters. The orthopedic service was consulted and they performed a left shoulder arthrocentesis that ruled‐out septic arthritis. Postprocedure, the patient was started on IV vancomycin. With no clear source of infection, there was concern for possible endocarditis. Transesophageal echocardiogram (TEE) was ordered and an electrophysiology (EP) consult was called. The pacemaker was interrogated, and the findings indicated that the right ventricular (RV) lead was dislodged. It was also noted by the EP service that the admission EKG showed a ventricular‐paced rhythm with a wide QRS complex and a right bundle branch block pattern, whereas the previous EKG (Fig. 2), from 3 months earlier, showed a ventricular‐paced rhythm with a narrow QRS complex consistent with a biventricular pacer. TEE showed an RV lead vegetation. The PPM was removed and a temporary pacemaker was placed until a new PPM could be placed. Blood cultures ultimately grew out Staphylococcus lugdunensis, and the patient was discharged to complete a course of IV cefazolin.
Endocarditis is a diagnosis commonly encountered by hospitalists and nearly every patient admitted by a hospitalist gets a baseline EKG in the ED prior to admission. Often, when a physician encounters an EKG with a ventricular‐paced rhythm, it is assumed that little could be learned from the EKG and no attempt is made to compare it to prior tracings. In this case, the prior EKG was immediately accessible through the electronic medical record system, but it was never reviewed. The EKG offered the first clue that there was a problem with the RV pacemaker lead, but initially, it was completely overlooked. This case teaches us that complications from endocarditis can present with EKG changes and that it is important to always compare admission EKGs to prior tracings when they are available.
The purpose of reporting this case is to highlight the importance of comparing admission EKGs with prior tracings, even when the admission EKG shows a ventricular‐paced rhythm.
To cite this abstract:Feldhamer K. A Case of Endocarditis Diagnosed by Ekg. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 362. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/a-case-of-endocarditis-diagnosed-by-ekg/. Accessed March 20, 2019.