continous fever following rastelli procedure

son born with tga, asd, vsd and had PS. at 4 yr old son did rastelli procedure 2 months ago. all went well but sutures reopened resulting in staphylococcus infection. sutures  reclosed tru surgery before giving iv treatment of cephalexin. sutures reopened again cause treatment was not given for enough time. started another course of cephalexin and fusidic acid and sutures granulated and closed. Now ptoblem is that after two weeks my son has been having  very high  fever for the past 8 days, is on 4 different antibiotics tru IV to treat any fungal deseases, endocarditis etc.Doctors can't find reason for continous fever as a CT Scan showed only some tiny spots in lungs and echo showed no signs of vegetation on or around gortex or graft. Please if you heard of any similar situations or you have any suggstiond please help. thanks  

[Jeffrey R Boris, M.D.]

Dear Heartmum,

This is a difficult situation.  For our other readers, the heart diagnosis was transposition of the great arteries (TGA), atrial septal defect (ASD), ventricular septal defect (VSD), and pulmonary stenosis (PS).  The Rastelli procedure sends blood through the VSD to the transposed aorta with what is called a baffle, a patch that directs the blood to the aorta and closes it off to the right ventricle.  Then, a homograft (a cadaveric pulmonary valve) is attached to the right ventricle and brought out to the pulmonary arteries to establish blood flow to the lungs.  What has happened here is what sounds like a wound infection and probable mediastinitis, an infection of the space inside and behind the wound, inside the chest, and around the pedicle of the heart and lungs.  What can happen after this, though, if treatment inadequately kills all the bacteria, is that other resistant bacteria or fungus can enter the wound or the blood stream and either be resistant to therapy, if they are surrounded by a vigorous inflammatory response (abscess) or if they are just resistant to the specific antibiotics, or cause other body site infections, such as endocarditis (infection of the lining of the heart) or other sites.

Without evaluating all of your son’s data, it is difficult to say what is causing him to continue to be febrile.  Sometimes, endocarditis does not demonstrate a vegetation but still exist; it can be diagnosed with large volume blood cultures left to incubate for 2 weeks.  As well, bacteria in the blood stream may have gone to other sites, such as the bone, joints, muscles, etc.  Therefore, they may need to look outside of the chest for evidence of infection.  Also, certain medications can cause what is called, “drug fever,” so it would be important to re-evaluate the medication regimen that he is on to ensure that he is not on any antibiotics that would increase this risk.