ENDOCARDITIC VEGETATIONS IN THE RIGHT HEA RT AFTER PACEMAKER IMPLANTATION AS A CAUSE OF A ROUND PULMONARY INFILTRATE

History and clinical findings: A 57-year-old man developed intermitten t fever and fatigue 11 months after a two-chamber cardiac pacemaker ha d been implanted because of 2 degrees and 3 degrees A-V block. Antitub erculosis treatment was initiated as tuberculosis was suspected. The i nfiltrate regressed, but the other symptoms persisted. Four months lat er he was admitted as an emergency because of septicaemia. Investigati ons: In addition to a recently discovered cardiac murmur there was a r aised erythrocyte sedimentation rate (116 mm) and leucocytosis (13 600 /mu l) with shift to the left. Coagulase-negative staphylococci were g rown on several blood cultures. Transoesophageal echocardiography (TOE ) demonstrated vegetation on the tricuspid valve, the pacing wires and the right ventricular outflow tract. Diagnosis, treatment and course: After the diagnosis of infective endocarditis had been established, a ntibiotic treatment was give with imipenem, gentamycin and teicoplanin , the pacemaker system and adherent thrombotic material were removed a nd a DDD pacemaker implanted from the other side. The patient remained free of symptoms during a follow-up period of 12 months. Interpretati on: Delayed diagnosis of infective endocarditis is not uncommon, becau se of the scarcity of typical symptoms. Repeated blood cultures and TO E are essential for the diagnosis.