Rhe-1. Enterococcal pacemaker endocarditis in a patient on etanercept.
A 78-year-old white female patient with rheumatoid arthritis (RA)
and non-ischemic cardiomyopathy status-post implantation of a
biventricular pacemaker 2 years earlier presented at an outside hospital
2 months earlier with chills, night sweats and malaise for weeks. Her RA
medications originally included Plaquenil, leflunomide and etanercept.
Blood cultures were positive for Enterococcus faecalis. Her RA
medications were all stopped. Transesophageal echocardiogram (TEE)
showed vegetation attached to the endocardial lead in the right atrium.
She was treated with intravenous ampicillin and gentamicin. Extensive
gastroenterology workup revealed no obvious source. TEE repeated after 5
weeks showed increase in size of vegetation. She was transferred to our
hospital for further management. Her biventricular pacer system
including the pulse generator and three intravascular leads were
removed. Cultures from the leads and blood were negative. She continued
her intravenous ampicillin and gentamicin for a total of 2 weeks post
pacer extraction. Etanercept is a recombinant DNA-derived protein that
binds tumor necrosis factor (TNF) and affects the role that TNF plays in
the inflammatory processes of RA. Serious infections including
pyelonephritis, septic arthritis, abdominal abscess, osteomyelitis,
pneumonia and sepsis have been reported in the clinical trials in
patients on etanercept. A recent study reported that electrode lead
endocarditis is a rare complication occurring in <1% of pacemaker and
ICD implants. This is the first reported case of a patient on etanercept
with pacemaker endocarditis. Repeat procedures during implantation of
the pacemaker along with rheumatoid arthritis and the medications
including leflunomide, Plaquenil and etanercept might have all had a
role to play in causing her pacemaker endocarditis. The above case lends
more evidence to the possibility that the TNF-blockers might predispose
to serious infections The role of etanercept in the treatment of
rheumatic disease is well-established and ongoing vigilance for
development of infections is recommended.
Arun Kalyanasundaram, MD, Robert Gotoff, MD, Michael Foltzer. MD,
Anwer Qureshi, MD, Randle Storm, MD, and James Perruquet, MD.