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Brain & Heart UVC-related infective endocarditis and septic emboli

malposition, and blood product usage) and those related clinical context, catheter type, and ongoing catheter-
to the individual’s underlying disease and its treatment related needs [3,17] . Adhering to current anticoagulation
(newborns, birthweight <1250 g, hematocrit >55%, small recommendations, we employed UFH or LMWH using
for gestational age, and administration of hyperosmolar the above PTT and anti-Xa goals for catheter-associated
[17]
medications) [3,8-11] . A systematic review encompassing 89 thrombosis . Certain experts advocate for an assertive
studies identified low birth weight, prematurity, congenital stance on thrombus treatment, suggesting the use of
abnormalities, and extended UVC duration, as well as tissue plasminogen activator (TPA) when the following
exposure to hyperosmolar fluids and medications, along criteria are met: A clot size >4 – 5 mm in any dimension,
with low-lying and malpositioned UVC, as risk factors for the presence of pedunculation, mobility, a snake-like
UVC-related infections . shape, and symptomatic [18-20] . While infants have been
[8]
successfully managed using TPA even in the setting of
In this case, thrombosis likely stemmed from the thrombocytopenia , our patient was at high risk for
[21]
malpositioning of the UVC. Contributing factors to hemorrhagic conversion given the presence of the left
thrombosis development described in this case might parietal lobe hemorrhagic infarcts, evoking concern for an
include UVC-related infections, endothelial injury, and embolic event. The lack of thrombus resolution following
a heightened state of hypercoagulability. Studies have our chosen anticoagulation strategy was within expectation,
reported the incidence of intracardiac thrombus formation particularly considering the thrombus size. However, the
to be as high as 26% in instances of malpositioned UVCs, use of TPA to dissolve the clot was deemed perilous for our
in contrast to 3% for well-positioned catheters . This patient.
[2]
erroneous UVC placement can precipitate nonbacterial
thrombotic endocarditis, leading to subsequent The 2015 AHA scientific statement outlining the
embolization and potentially serving as a nidus for management of IE in childhood recommends that patients
bacterial superinfection . It warrants speculation whether with MSSA endocarditis involving a native valve and/or
[12]
a different course might have altered, the outcome had cardiac tissue should be treated with intravenous nafcillin
[22]
the displaced UVC, which later migrated, been promptly or oxacillin for 4 – 6 weeks . To expedite bacterial
repositioned on DOL 5. With the growing survival rates of elimination, gentamicin is typically introduced for the first
[22]
critically ill neonates and the increased utilization of central 3 – 5 days . For instances where a patient has a penicillin
venous catheters, there has been an increase in reported allergy, a first-generation cephalosporin can be used as an
[22]
cases of IE within this demographic [13,14] . Anteroposterior alternative, with the optional addition of gentamicin . For
chest-abdominal radiograph has emerged as the most patients with methicillin-resistant Staphylococcus aureus
endocarditis involving a native valve and/or cardiac tissue,
commonly used imaging method for ascertaining UVC the treatment regimen involves vancomycin administration
placement. Assessment methods include counting vertebral for a minimum of 6 weeks, with or without gentamicin for
bodies or assessing the cardiac silhouette. Optimal UVC the first 3 – 5 days of therapy . In scenarios where a patient
[22]
positioning is achieved when it aligns with the eighth presents with a prosthetic valve or material involvement,
and ninth thoracic vertebral bodies or corresponds to the eradication of the infection becomes much more complex
cavoatrial junction (based on extrapolating the curve of and is associated with elevated mortality, prompting the
the right atrial border and its intersection with the IVC addition of rifampin to the antibiotic regimen and the
[15]
medially on the right side of the vertebral bodies) . An removal of the infected material . Surgical intervention
[22]
alternative approach for identifying the UVC tip position is for IE, particularly in infancy, is associated with high
through a targeted echocardiogram, which has been shown mortality [23,24] . Indications for surgical management of
to outperform radiography in detecting malpositioned IE include persistent vegetations post-embolization,
catheters . To ensure consistent and accurate UVC continued growth or extension despite 4 weeks of
[16]
placement, a potential solution might involve providing treatment, heart failure, or perivalvular extension causing
clinicians with basic training in targeted echocardiography heart block . In our patient’s case, concerns about septic
[22]
to accurately determine appropriate UVC positioning. emboli affecting the brain and lungs prompted the need for
The effective management of IE involving septic surgical intervention.
thrombosis related to UVC placement necessitates
prompt diagnosis, timely administration of antibiotics and 4. Conclusion
anticoagulants, and continuous surveillance for embolism. This patient’s case offers a unique and effective treatment
While the approach for treating thrombosis associated with approach for a complex case scenario involving intracardiac
catheters through anticoagulation relies on expert-guided thrombosis, infective endocarditis, and septic emboli, all in
recommendations, it is heavily dependent on the specific relation to a malpositioned UVC in a newborn. This case

Volume 1 Issue 2 (2023) 4 https://doi.org/10.36922/bh.1005