Infective Endocarditis Presenting as Complete Heart Block With an Unexpected Finding of a Cardiac Abscess and Purulent Pericarditis

Abstract

Intracardiac abscess resulting in complete heart block is an infrequent complication of infective endocarditis. Most presentations of endocarditis are limited to valvular and perivalvular structures, with varying degrees of heart block occurring in the minority of cases. We report a case of endocarditis manifesting as chest pain associated with ST segment elevation and complete heart block. The patient expired unexpectedly within a few hours of presentation. Postmortem examination revealed an atrial septal abscess, purulent pericardial collection, and fibrinous pericarditis. Spread of the abscess into the atrial septum was postulated to be the cause of the complete heart block. In endocarditis, the ominous development of heart block and a poor response to antibiotic therapy imply significant extension of the infection. Management therefore requires prompt ventricular pacing with consideration for valve replacement and possible pericardial drainage.

Keywords: Heart block; Infective endocarditis; Myocardial abscess; Purulent pericarditis.

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

Gray exudate on granular epicardial surface consistent with fibrinopurulent pericarditis.

Figure 3

Photomicrograph (original magnification × 250) of the pericardium with severe inflammation, neutrophilic infiltration and fibrin with entrapped clusters of bacteria.

Figure 4

Gross view of the heart showing the abscess in the atrial septal wall (arrow). LV: left ventricle. LA: left atrium.