Discussion:

Neisseria gonorrhea endocarditis is a rare complication of DGI and represents 0.5 to 3% of such cases1. Although CIED pocket infection has been reported in DGI13, to our knowledge this is the first report of CIED associated gonococcal endocarditis. Acute and subacute CIED infections are typically attributed to coagulase negative Staphylococcus where as, chronic infections are largely caused by S. Aureus (50%) and coagulase negative staphylococci (50%) in more than 95% of cases.2 Although rare, gonococcal endocarditis carries high mortality and virulence, which highlights the importance of awareness in the proper clinical context. Notably, initial blood cultures are negative in 50% of disseminated gonococcal infections.5
Cardiac involvement in DGI is associated with high morbidity and mortality due to large vegetations, valvular destruction, electrical instability due to conduction system involvement, and rarely myocarditis which can be associated with malignant arrhythmias and sudden cardiac death.6-8 Due to antibiotic resistance, large vegetation size, and valvular destruction, gonococcal endocarditis is often managed with surgical debulking and valve repair. However, transvenous catheter based debulking may be a viable alternative in the absence of valvular heart failure or in patients who are not surgical candidates.
Over the last three decades there has been a significant increase in cases of CIED associated endocarditis necessitating lead extraction.9 When vegetations are > 2cm in size, an open surgical approach is considered. Due to increasing patient age and comorbidity, a number of these patients are not candidates for surgical debulking and repair. Richardson et al. (8 patients) and Mirsa et al. (5 patients) have reported successful thrombus/vegetation debulking (average size of 2 and 3 cm respectively, subsequently decreased to <1cm and 2 cm) with the Penumbra Aspiration System (Penumbra Inc, Alameda, CA) prior to CIED extraction. Major complications of these case series included small septic emboli, sepsis, and death unrelated to the procedure.10,11
This case illustrates the potential utility of catheter based vegetation debulking prior to CIED extraction in a condition often treated surgically. We employed joint decision making with our patient, who chose the option of a wearable cardiac defibrillator and close follow-up before possible CIED re-implantation.