Management of Patent Ductus Arteriosus Endarteritis in Children

Abstract

The risk of patent ductus arteriosus infective endarteritis (PDA-IE) has significantly reduced since the introduction of antibiotics and surgical or interventional treatment strategies. However, diagnosis and adequate, timely management of PDA-IE remains challenging. We present the case of a 9-year-old girl with PDA-IE, illustrating our strategy to minimize complications in pediatric patients.

Keywords

patent ductus arteriosus - endarteritis - management

Introduction

Infective endarteritis (IE) is a rare but severe complication in patients with patent ductus arteriosus (PDA). Prior to antibiotic treatment, IE accounted for an estimated 45% of deaths in this patient population.[1] Nowadays, PDA-IE is extremely rare, and its incidence has declined due to routine surgical closure, changes in socioeconomic circumstances, and improved dental health.[2]

Complications of PDA-IE include vegetations in the pulmonary artery or at the pulmonary valve and septic pulmonary embolism. Rupture is a rare, but life-threatening complication due to aneurysm formation.[3]

Management of acute PDA-IE remains challenging, and currently, no recommendations regarding timing and approach of surgical intervention and the role of advanced imaging techniques exist.[4] This case report summarizes our approach.

Case Description

A previously well 9-year-old girl was referred to our center with IE associated with an undiagnosed PDA. The patient presented to a local hospital with persistent nausea, fatigue, abdominal discomfort, but was initially discharged. Eight days later, the patient returned with fever, cough, an urticarial rash, pleuritic chest, and left hip pain. The patient reported 5 kg of weight loss over the preceding month.

On examination, the patient was febrile 38.8°C with mild tachycardia and tachypnea. There was a new 4/6 continuous murmur with thrill. Splenomegaly and left upper quadrant tenderness were appreciable. A single 4-mm Janeway lesion of the plantar surface of the right foot was noted.

Echocardiogram demonstrated a moderate-sized PDA with left-to-right shunting, left ventricular dilatation (left ventricular end-diastolic volume: 138 mL, Z-score +5.4, [Fig. 1A, B]), and low normal left ventricle function (ejection fraction: 56%). No indirect signs for pulmonary hypertension, including normal right ventricular systolic pressure and no flattened interventricular septum. Bloods showed elevated C-reactive protein of 13 mg/L. Chest X-ray demonstrated mild cardiomegaly and increased pulmonary vasculature markings. Peripheral blood cultures grew a pan-sensitive Streptococcus sanguinis. The patient was started on intravenous amoxicillin plus clavulanic acid on day 2 of admission with immediate defervescence of fever and improvement in fatigue and was changed to ceftriaxone on day 7.

Fig. 1 (A) Four chamber view with volume loaded left ventricle. (B) Ductal view with large PDA and left-to-right shunting. (C) 3D-reconstruction of cardiac CT showing PDA. 3D, three-dimensional; CT, computed tomography; PDA, patent ductus arteriosus.

A cardiac computed tomography (CT) was performed to characterize the PDA morphology and exclude aneurysm formation ([Fig. 1C]). There was thickening around the duct and multiple small opacities throughout the lungs bilaterally suspicious for septic emboli.

The patient continued antibiotic treatment and underwent a ligation and division of the PDA on day 15 after hospital admission. The preoperative transesophageal echocardiogram (TOE) showed a vegetation in the main pulmonary artery (MPA) where the PDA jet was directed to. The procedure was performed via median sternotomy on cardiopulmonary bypass. The PDA was divided and the vegetation in was removed, requiring an MPA-plasty. Postoperative course was uncomplicated and intravenous antibiotics were continued for additional 4 weeks after surgery. The family of the patient provided informed consent to present these data.

Discussion

Across the literature, treatment strategies for pediatric PDA-IE are variable, and different timing and surgical approaches are described ([Supplementary Table S1], available in online version).

Most authors treat with antibiotics for 4 to 6 weeks, with surgical ligation following the antibiotic course. Acute complications of PDA-IE may occur and include aneurysm formation, periductal hematoma, and rupture of the PDA, which we have experienced in an historic case with fatal outcome.[3] From this experience our management has changed to minimize the risk of life-threatening complications and carefully plan the surgical approach.

Our algorithm ([Fig. 2]) includes an early CT angiogram when PDA-IE is suspected on transthoracic echocardiogram (TTE), to determine if an aneurysm warranting immediate surgical intervention, large vegetations, or pulmonary emboli are present. Aneurysms either form a thin-walled saccular or fusiform dilatation of the ductus arteriosus. In the absence of an aneurysm or hematoma, the patient should receive antibiotic treatment at for approximately 2 weeks prior to surgery. If fever is persistent despite appropriate antibiotic treatment, we suggest to proceed with urgent surgery. If there is suspicion of pulmonary hypertension on echocardiogram, pulmonary hypertension needs to be excluded by invasive testing.

Fig. 2 Strategy for pediatric PDA-IE. CT, computed tomography; PDA-IE, patent ductus arteriosus infective endarteritis; TOE, transesophageal echocardiogram.

In addition to a transthoracic echocardiogram, we perform a TOE prior to surgery to assess for pulmonary vegetations or lesions, which might influence the surgical approach. Depending on the findings and patient's age and weight, it might be beneficial to perform duct ligation and resection of vegetations via median sternotomy on cardiopulmonary bypass rather than lateral thoracotomy. This has been described in the literature when larger vegetations in the pulmonary arteries or at the pulmonary valve were present. In more recent studies, transcatheter closure of the PDA after completing antibiotic treatment has been described in selected cases.[5] This should only be considered in patients whose bacteremia is cleared by antibiotics and who have no aneurysm, vegetation, or adventitial/intimal thickening.

Conflict of Interest

None declared.

Acknowledgment

We thank the family for the consent to share this case.

Availability of Data and Material

All relevant data are within the manuscript and its supporting information files.

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Publication History

Received: 22 June 2024

Accepted: 09 August 2024

Accepted Manuscript online:
17 October 2024

Article published online:
21 November 2024