Description

A 68-year-old man who 1 year previously had been fitted with a permanent pacemaker implantation (PPI) for symptomatic sinus bradycardia was admitted with recurrent syncope and intermittent moderate-grade fever for 2 months. He was on intermittent antibiotics from rural health centre for the same duration with no improvement in his condition.

On examination, he was frail with exteriorisation of the pacemaker (figure 1) with pus exuding from the pacemaker pocket. Transoesophageal echocardiography revealed subvalvular vegetation suggestive of subacute bacterial endocarditis (SBE). All other haematological and biochemical parameters were normal. Pus culture from the pocket revealed Gram-positive cocci in groups sensitive to β-lactams and vancomycin. Repeated blood cultures were sterile. He was managed with removal of pacemaker/leads, management of SBE with antibiotics (vancomycin with ceftriaxone) for 3 weeks, transient glycopyrrolate/external pacemaker management and replacement of pacemaker on a later date on opposite side.

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Figure 1

Exteriorised pacemaker in a case of implantation site infection leading to skin necrosis.

Pacemaker pocket erosion caused by generator is usually a result of pocket infection which later leads to exteriorisation of the pacemaker. It is a rare complication of PPI (incidence <1%) commonly seen in elderly patients with decreased subcutaneous fat/fragile skin, PPI in a small pocket, use of harsh/strong disinfectants with increased scrubbing and prolonged steroid intake.1 Exteriorisation obligates intense antibiotics therapy and removal of the pacemaker owing to bacterial contamination and its intravascular/intracardiac spread through pacemaker leads.2

Prophylactic anti-staphylococcal antibiotic treatment during implantation may prevent not only PPI infections but also pacemaker exteriorisation linked to hidden infections.3