A Complex Case of AICD Lead Endocarditis with Dual Bacterial Infections and Subsequent Lumbar Discitis in a Patient with Multiple Comorbidities: A Case Report

Case Diagnosis: 55 year-old male with automatic implantable cardioverter-defibrillator (AICD), lead endocarditis, extended-spectrum beta-lactamase (ESBL) Escherichia coli and imipenem-sensitive Pseudomonas aeruginosa bacteremia, and L2 discitis/osteomyelitis.

Case Description or Program Description: 55 year-old male with a history of heart failure with reduced ejection fraction, hypertension, coronary artery disease, atrial fibrillation, insulin-dependent diabetes, hypothyroidism, AICD placement, and recent percutaneous coronary intervention to the left circumflex artery presented with signs of sepsis and back pain. Patient had been transferred from another hospital for escalation of care due to AICD lead endocarditis associated with ESBL E.coli and imipenem-sensitive Pseudomonas bacteremia. In addition, the patient complained of significant lower back pain.

Setting: Tertiary Care Hospital

Assessment/Results: The patient was started on IV meropenem upon admission and was promptly seen by cardiology for AICD lead extraction. Subsequently, the patient was found to have L2 discitis/osteomyelitis confirmed by magnetic resonance imaging. The Pain Service was consulted a week after admission due to uncontrolled lower back pain. Pain management was improved after changing morphine and fentanyl to scheduled oxycodone and remaining on antibiotic treatment.

Discussion (relevance): Patients with indwelling devices are at risk for infection and hematogenous spread. Musculoskeletal pain is common in infectious endocarditis, and vertebral osteomyelitis should be considered in these patients. Vertebral osteomyelitis has been shown to complicate infectious endocarditis in up to 20% of patients. Furthermore, the presence of vertebral osteomyelitis with infectious endocarditis almost doubles the hospital mortality rate. Early recognition and appropriate management are essential to preventing complications and improving outcomes.

Conclusions: This case highlights the importance of early recognition and pain management of AICD lead endocarditis and vertebral osteomyelitis, especially in patients with multiple comorbidities. Prompt intervention, including device removal and appropriate antimicrobial and pain therapy, is essential to prevent complications and improve patient outcomes.