Cardiac Device-Related Infective Endocarditis Presenting With Suspected Embolic Stroke in a Patient With a Legacy Implantable Cardioverter-Defibrillator: A Case Report

Cardiac device-related infective endocarditis can evade early recognition when embolic neurologic symptoms obscure the underlying cardiac source. We report the case of an 87-year-old man with a cardiac resynchronization therapy defibrillator (CRT-D) that was not labeled as MRI-conditional. He presented after an unwitnessed fall with acute dysarthria, facial asymmetry, and asymmetric extremity weakness, with a National Institutes of Health Stroke Scale score of 10 during the acute stroke evaluation. Initial cardiovascular examination revealed no murmur, and noncontrast CT of the head showed no acute intracranial abnormality. Diffusion-weighted MRI could not be obtained at the presenting institution because of his non-MRI-conditional cardiac hardware. Over the subsequent hospital course, his condition progressed to multiorgan failure, marked by worsening baseline thrombocytopenia, acute renal dysfunction, and hyperbilirubinemia. Admission blood cultures grew Streptococcus agalactiae, prompting transesophageal echocardiography (TEE), which demonstrated a mobile vegetation attached to the CRT-D lead and confirmed lead-associated infective endocarditis. This case illustrates how a non-MRI-conditional cardiac implantable electronic device (CIED) can limit neuroimaging in patients with suspected cerebral ischemia and systemic infection. Clinicians should consider early TEE when focal neurologic deficits are accompanied by fever, bacteremia, or systemic toxicity in a patient with a CIED, even when the cardiovascular examination and initial CT neuroimaging are unrevealing.