PACEMAKER INFECTION WITH MYCOBACTERIUM TUBERCULOSIS:

A CASE REPORT

ABSTRACT

INTRODUCTION: Infection in a permanently implanted pacemaker is a serious

complication, and it is one of the main reasons for device removal and patient morbidity.

This paper will discuss a case with an unusual etiologic agent of pacemaker infection.

CASE DESCRIPTION: We are presented with an 81 year-old male, Filipino, known

diabetic who had a pacemaker (PM) implanted for complete heart block in 2012. The

patient presented at another institution more than two weeks prior to admission to our

institution with erythema and swelling in his left pectoral pacemaker pocket associated

with undocumented fever. A pacemaker effusion was aspirated and the fluid reportedly

tested positive for MTB complex. He was given anti-Kochs medications and oral

Amoxicillin-Clavulanate for two weeks and subsequently transferred to our institution

where he underwent explantation of his pacemaker after a temporary pacemaker was

installed. Of note was the unusual ease of lead removal. He was started on IV

Cephalosporin and continued on anti-Kochs regimen. The culture showed growth of

Stenotrophomonas specie and positive Polymerase Chain Reaction test of both ends of

the electrodes for Mycobacterium tuberculosis. Patient was then continued on anti-

Kochs medication and Vancomycin was added. A week later, a new dual-chamber

pacemaker was implanted in and the temporary pacemaker removed without incident

with good capture and sensing.

DISCUSSION/CONCLUSION: With advances in medical technology and devices, as

well as increasing life expectancy, more and more patients are seen requiring cardiac

implantable devices.The number of patients who receive pacemakers and subsequent

revisions or replacements have increased with corresponding increase in chances of

infection1. The rate of infection averages 1-2% in recent studies, ranging from 0.13 to

19.9% for series with intra-abdominal implantation, while it remains lower for

percutaneous implantation.1

The reason for these infections is presumed to be due to local contamination and

breach of the skin as a barrier, with resultant introduction of bacteria into the pocket.

Gram-positive bacteria in general and Staphylococci in particular, cause the majority of

infections (68%93%), while gram-negative bacteria are responsible for fewer than 18%

of infections.

Mycobacterium tuberculosis is an extremely rare causative agent for these

infections4. Majority of available reports which had tuberculosis as the agent were from

Asian countries and were only case reports. To the best of our knowledge, our patient is

the first documented tuberculous infection of a pacemaker system in our country, and

definitely the first in our institution.

INTRODUCTION: As the population ages, and as our management of heart disease

improves, more patients are living longer and many more with chronic heart diseases.

These become the population who are more likely to require Cardiac Implantable

Electronic Devices (CIED) like pacemakers, intracardiac defibrillators (ICD) and cardiac
resynchronization therapy (CRT) units. Furthermore, many of these patients also end up

receiving replacements of their pulse generators. Infection in a permanently implanted

pacemaker is a serious complication, and this is one of the main reasons for device

removal and patient morbidity. In the Philippines, although Mycobacterium tuberculosis

is endemic, but pacemaker infection by this organism has not been reported as yet.

CLINICAL CASE SUMMARY: We had an 81 year-old male, Filipino patient, known

diabetic, who was previous treated for pulmonary tuberculosis more than ten years ago.

He had a dual chamber pacemaker implanted in 2012 for complete heart block. He

presented a little over two weeks before admission at another institution with

undocumented fever and an erythematous fluctuant lump over of his pacemaker site,

which prompted consult. The pocket was aspirated and the fluid reportedly tested

positive for MTB complex. He was started on anti-Kochs regimen and oral Amoxicillin-

Clavulanate until his subsequent transfer to our institution. A temporary pacemaker was

inserted first and the infected pacemaker system was explanted. The pacemaker pocket

was cleansed and closed with a drain. During the procedure, the lead removal was

surprisingly easy and effortless, suggesting loss of integrity of the tissues surrounding

the endocardial tips of the electrodes. This is contrary to the general experience of

difficulty in extracting chronic leads, which frequently require special extraction

technique or device such as use of laser extraction system. Cultures of the pocket and

fluid as well as the electrode were sent with results showing growth of

Stenotrophomonas specie and both proximal and distal ends of the leads tested positive

by Polymerase Chain Reaction for Mycobacterium tuberculosis.The patient was

continued on anti-Kochs medication and Vancomycin was added on to the

Cephalosporin. In retrospect, the ease that the electrode tips came off suggests

infection with loss of integrity of the surrounding anchoring tissue.

One week later, a new dual chamber pacing system was implanted on the

opposite infraclavicular area and the temporary pacemaker was removed without

complication. The patient was discharged with instruction to complete full course anti-

Kochs regimen.

DISCUSSION: With the increase in the number of patients who receive CIED, as well

as the additional need of intervention during follow-up such as device change or

upgrade, chances of infection also increased. Gram-positive bacteria in general and

Staphylococci in particular cause the majority (68%93%) of infections, while gram-

negative bacteria cause fewer than 18% of infections. Approximately 15% of infections

are culture negative.2,3

Most available Asian studies which had tuberculosis as the agent were only case

reports4, since this is not the common pathogen that is found in most series on

pacemaker site infection4. Kumar et al reported a case series of only three Indian

patients who presented with infection of their pacemaker site caused by Mycobacterium

species.11

Among all skin and soft tissue infections caused by rapidly-growing

Mycobacterium, those on the chest or back seem more likely to result from M. fortuitum

than from other Mycobacterium species8. Padke, et. al, reported a case of M. fortuitum

infection in a patient with a pacemaker and in his review he reported that among the 21
case-patients, for which time of onset was reported, 5 (24%) of infections developed
6
more than 6 months after the most recent device manipulation.

In his discussion, Johansen et al, in the analysis of the Danish registry, noted that

increased infection rate after repeated procedures (most often simple pulse generator

replacements) is unexpected, as these procedures usually involve only a minor surgical

revision and are short-lasting compared with first implantations. However, the author

also noted that revision surgery is an important risk factor for the infection of an

implanted prosthesis or device which could likely be explained by the fact that PM

pockets can be colonized by bacteria, even in the absence of any initial clinical signs of

infection. The combination of a limited immunological response of the fibrous and poorly

vascularized PM pocket that is opened during replacement or revision procedures, and

the rapid formation of a microbial biofilm by either latent or perioperative inoculation of

pathogens allow the development of pocket infection. 1

The source of early-onset CIED infections is more likely inoculation of the

organism into the pocket at the time of the implantation procedure. This source

contrasts with the probable source for the 8 reported CIED infections caused by M.

tuberculosis complex, manifesting >11 months after device implantation. These

infections more likely resulted from reactivation of previous tuberculous disease,

mycobacteremia, and secondary seeding of the device 6. Our patient presented with

infection 4 years after the implant.

In our local setting, a retrospective study by Sevilla, et al conducted in the

Philippine Heart Center from January 1990 to December 1999 found a total of 34
patients with pacemaker infection. None of those were cause by MTB. They concluded

that the optimal treatment for the large majority of these patients was removal of the

entire infected pacing system, with a short course of culture-guided antibiotic therapy.

Time interval from the most recent pacemaker procedure and the recognized onset of

the subsequent pacemaker infection varied widely. Majority had late onset of infection

(more than 6 months after the surgery). 33% had intermediate onset of infection (2

weeks to 6 months from procedure). 12 Staphylococcus aureus was still the most

common isolate from those patients who had positive bacteremia during presentation. 12

Review of published data in the Philippine setting has provided no currently

reported case of pacemaker site infection with Mycobacterium as the infecting organism

despite the widespread nature of pulmonary and extra-pulmonary cases of tuberculosis.

The epidemiological burden of Mycobacterium tuberculosis in the Philippines as

reported by WHO in 2013 has a prevalence rate of 438 (385495)/100,000 population

(WHO, 2014).12

CONCLUSION: We presented a case of late onset tuberculous infection of a

pacemaker system 4 years after its implantation. The extension of the infection to the

distal tips of the electrode probably made their extraction unusually easy. He was

treated by explantation with temporary pacemaker take over, followed a week later by

implantation of a new system via a new access site while on antibiotics. He was

discharged on short term antibiotics plus full course of anti-tuberculous regimen.

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Copyright 2000.