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Challenges in Clinical Electrocardiography |

PR Interval Prolongation in a Patient With Infective Endocarditis Subtle Changes of Serious Complications

Bhaskar Bhardwaj, MD1; Devika Kapuria, MD1; Shariq Shamim, MD2
[+] Author Affiliations
1Department of Internal Medicine, University of Missouri–Kansas City, Kansas City
2St Luke’s Mid America Heart Institute, University of Missouri–Kansas City, Kansas City
JAMA Intern Med. 2016;176(6):841-843. doi:10.1001/jamainternmed.2016.1644.
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A man in his 80s presented with weakness, fever, and chills of 1 week’s duration. His medical history was significant for severe aortic stenosis, heart failure with preserved ejection fraction, and end-stage renal disease requiring hemodialysis. His physical examination was unremarkable except for a hyperdynamic precordium, late peaking grade 3/6 ejection systolic murmur best auscultated over the aortic area, and pulsus parvus et tardus. Results from his laboratory tests were significant for a leukocyte count of 17 600/µL (17.6 × 109/L), a hemoglobin level of 11.8 g/dL (118 g/L), a platelet count of 97 × 103/µL (97 × 109/L), and a troponin level of 2.46 ng/mL. No electrolyte abnormalities were noted. Results from a urinalysis were negative for infection. An electrocardiogram (ECG) was performed (Figure 1).

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Figure 1.
Sinus Tachycardia, Left Bundle Branch Block, and Marked PR Interval Prolongation of 360 Milliseconds
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Figure 2.
Normal Sinus Rhythm, Left Bundle Branch Block, and Normal PR Interval of 156 Milliseconds
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Figure 3.
Transesopheageal Echocardiogram

A, The red arrowhead indicates the 0.8-cm vegetation. B, The yellow arrowhead indicates an annular abscess; blue arrowhead, the extension of the abscess into the right atrium.

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Figure 4.
Leads III and II

A, Lead III showing P waves buried in T waves (black arrowhead). B, Notching of lead II is due to P waves (blue arrowhead) buried in T waves (red arrowhead).

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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Multimedia

Video 1.

Transesophageal Echocardiogram, Long-Axis View

Mid-esophageal, Long-Axis View Showing Vegetation on the Right Coronary Cusp

Video 2.

Transesophageal Echocardiogram, Short-Axis View

Mid-esophageal, Short-Axis View Showing Aortic Valve Ring Abscess With Extension to the Right Atrium

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