A 79-year- old man comes for him scheduled six month visit.
Three years ago he had a pacemaker implanted for complete heart block which resulted in a syncopal episode.
He tells us that he feels poorly for the last two weeks following a dental procedure
to remove several badly infected teeth.
He says specifically he feels tired, sweaty, loss of appetite
and he’s had recently several shaking chills.
Blood pressure a little elevated but not bad for a man his age, heart rate slightly elevated,
temperature definitely elevated, normal would be 37 and he has signs of an infection.
His complete blood count shows that his white cell count is 14,000 with 85% polymorphonuclear cells,
normal should be less than 10.000 with about 60% to 70% polys
so this is clearly there’s an infection somewhere.
So again, the critical factors - he's had 3rd degree heart block,
he was appropriately treated with a pacemaker and there’s a history of a recent infectious process
where he had badly infected teeth removed
and of course he has symptoms that suggest a fibrile syndrome probably an infection
and he’s blood pressure is a little bit elevated but that’s not so worrisome, this is much more worrisome, his fever.
And again of course the white count with the polys tells us that there’s an active infectious process.
Here's his pre-pacemaker EKG which shows complete heart block.
There’s no relationship between the P waves and the QRSs.
You should take a moment just to look at it to notice that there’s not a P in front of each QRS
and of course the heart rate is markedly slow, there’s a wide QRS
because that’s a ventricular pacemaker that takes over
and again as mentioned no regular relationship between P waves and QRSs
and the diagnosis was appropriate, 3rd degree AV block and of course he had a pacemaker implanted.
This is a little diagram showing you a DDD pacemaker that is it is paces
and senses in both the atrium and the ventricle and is inhibited if the heart rate itself is adequate.
Here’s a chest x-ray from a patient with a single lead VVI pacemaker that is it senses
and paces only in the right ventricle not in the right atrium
and you can see very easily on this chest x-ray of the pacemaker box implanted.
Here we see again his 3rd degree heart block, he gets some blood cultures, they grow staph aureus.
We do an echocardiogram that shows possible vegetation on the pacemaker wire.
So what do we do? We have to remove both the wire and the pacemaker.
The patients gets a course of intravenous vancomycin for a long time.
He gets a permanent pacemaker implantation
and then next time he goes to the dentist he needs prophylactic oral antibiotics.
Now, what happens when we take out the pacer wire?
We’ll he’s gonna go back to 3rd degree heart block
so very often we have to implant a temporary pacemaker,
once we’ve given a few days of intravenous vancomycin.