title: Aggregatibacter aphrophilus pacemaker endocarditis: a case report.
abstract: BACKGROUND
  Aggregatibacter bacteria are a rare cause of endocarditis in adults. They are part of a group of organisms known as HACEK--Haemophilus, Aggregatibacter, Cardiobacter, Eikenella, and Kingella. Among these organisms, several Haemophilus species have been reclassified under the genus Aggregatibacter. Very few cases of Aggregatibacter endocarditis in patients with pacemaker devices have been reported.
  
  
  METHODS
  We present here what we believe to be the first case of Aggregatibacter aphrophilus pacemaker endocarditis. A 62-year-old African American male with a medical history significant for dual-chamber pacemaker placement in 1996 for complete heart block with subsequent lead manipulation in 2007, presented to his primary care doctor with fever, chills, night sweats, fatigue, and ten-pound weight loss over a four-month period. Physical examination revealed a new murmur and jugular venous distension which prompted initiation of antibiotics for suspicion of endocarditis. Both sets of initial blood cultures were positive for A. aphrophilus. Transesophageal echocardiogram revealed vegetations on the tricuspid valve and the right ventricular pacemaker lead (Figure 1). This case highlights the importance of identifying rare causes of endocarditis and recognizing that treatment may not differ from the standard treatment for typical presentations. The patient received intravenous ceftriaxone for his endocarditis for a total of six weeks. Upon device removal, temporary jugular venous pacing wires were placed. After two weeks of antibiotic treatment and no clinical deterioration, a new permanent pacemaker was placed and the patient was discharged home.
  
  
  CONCLUSIONS
  This is the first case of A. aphrophilus endocarditis in a patient with a permanent pacemaker. Our patient had no obvious risk factors other than poor dentition and a history of repeated pacemaker lead manipulation. This suggests that valvulopathies secondary to repeated lead manipulation can be clinically significant factors in morbidity and mortality in this patient population.
authors.forename: Sahil R
authors.initials: SR
authors.lastname: Patel
authors.affiliation: Department of Internal Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA. npatel11@drexelmed.edu.
authors.forename: Nishi H
authors.initials: NH
authors.lastname: Patel
authors.forename: Amit
authors.initials: A
authors.lastname: Borah
authors.forename: Heath
authors.initials: H
authors.lastname: Saltzman
mesh_terms: D064207:Aggregatibacter aphrophilus / Q000302:isolation & purification* / Q000472:pathogenicity; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002443:Ceftriaxone / Q000627:therapeutic use; D017548:Echocardiography, Transesophageal; D004697:Endocarditis, Bacterial / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000382:microbiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial
chemical_list: D000900:Anti-Bacterial Agents; D002443:Ceftriaxone