A case of fever of unknown origin and recurrent hospital admissions in a cardiac patient: emergence of Enterobacter cloacae

Abstract

A 72-year-old gentleman with significant cardiac history and a pacemaker in situ initially presented to the emergency department 5 days after he had his pacemaker-unit batteries changed. He had deranged vital signs, productive cough and fever. His chest plain radiograph did not show evidence of infection; however, he had right basal crackles on auscultation, which suggested a lower respiratory tract infection. He was treated with intravenous co-amoxiclav and supportive therapy, which led to his improvement. The patient was discharged but had to be readmitted a total of four times over the span of 4 months due to recurrent fever and associated symptoms. Transthoracic and transoesophageal echocardiograms and CT of the neck/thorax/abdomen/pelvis were done to look for endocarditis, pacemaker-unit infection and other sources of infection. However, these did not show any evidence of infection. He did have persistent raised inflammatory markers and two blood cultures growing Enterobacter cloacae. A fluorodeoxyglucose positron emission tomography scan was done, which showed evidence of pacemaker lead infection. His pacemaker unit was removed, which led to cessation of his symptoms and normalisation of his inflammatory markers. He had no further hospital admissions to date and has been regularly followed up in an outpatient cardiology clinic.