Fibrous Web in the Right Atrium: A Complication of Fungal Endocarditis and Previous Lead Infections

A 57-year-old woman with a past medical history of severe non-ischemic cardiomyopathy undergoing orthotopic heart transplant evaluation on milrinone, prior extraction of multiple pacemaker and implantable cardiover ter def ibr i l lator ( ICD) leads due to Staphylococcus epidermidis endocarditis, and multiple central venous catheter infections presented with several days of worsening dyspnea on exertion, orthopnea and lower extremity edema, prompting admission for congestive heart failure exacerbation. While she received aggressive intravenous diuretics, she was also found to be febrile to 101.8°F with a white blood cell count of 11,000/μL. Blood cultures were drawn, her peripherally inserted central catheter was removed, and she was started on broad spectrum antibiotics with imipenem and daptomycin. She remained hemodynamically stable, but several days into her hospitalization, her blood cultures grew Candida albicans. Antibiotics were stopped, and she was empirically started on anidulafungin. A transesophageal echocardiogram (TEE) was then performed and showed linear densities in the right atrium which mimicked the course of previously extracted leads (Figure 1), consistent with fibrous sheaths. Also seen was a 5 x 8 mm mobile vegetation on the ICD lead, multiple linear ‘web-like’ vegetations in the right atrium (Figure 2), and more typical-appearing vegetations in the superior vena cava (Figure 3). These findings, in addition to the fungemia, prompted transvenous ICD extraction, which she tolerated well. Her subsequent blood cultures were negative, but given her previous history of lead and line infections, the decision was made to fit the patient with a wearable defibrillator and re-evaluate her for infection in 6 weeks after completion of treatment for fungal endocarditis. After clearance of infection, her candidacy for cardiac transplant would also be re-evaluated.