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 Table of Contents  
Year : 2015  |  Volume : 1  |  Issue : 1  |  Page : 57-59

Atypical mycobacterial endocarditis in a permanent pacemaker implant patient

Department of Microbiology, Apollo Hospitals, Jubilee Hills, Hyderabad, Telangana, India

Date of Submission11-Jun-2015
Date of Acceptance15-Jul-2015
Date of Web Publication9-Nov-2015

Correspondence Address:
Ratna Rao
Laboratory Director, Appollo Hospitals, Jubilee Hills, Hyderabad, Telangana
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Source of Support: None, Conflict of Interest: None

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A 63-year-old man with permanent pacemaker implant developed cardiac device related endocarditis by atypical mycobacteria. Infection with rare organisms should be considered whenever the routine culture fail to pick up the causative pathogen. Timely diagnosis and management is essential for these infections.

Keywords: Atypical mycobacteria, cardiac device related endocarditis, pacemaker pocket infection

How to cite this article:
Rao R, Mani R. Atypical mycobacterial endocarditis in a permanent pacemaker implant patient. J Curr Res Sci Med 2015;1:57-9

How to cite this URL:
Rao R, Mani R. Atypical mycobacterial endocarditis in a permanent pacemaker implant patient. J Curr Res Sci Med [serial online] 2015 [cited 2021 Jul 30];1:57-9. Available from: https://www.jcrsmed.org/text.asp?2015/1/1/57/168930

  Introduction Top

With increasing incidence of cardiovascular diseases, permanent pacemaker implants (PPI) have become common. These patients are at an increased risk of acquiring infections by organisms ranging from commonly encountered bacteria such as Enterococcus and Staphylococcus to rare ones like atypical mycobacteria and fungi. Several reports of pacemaker endocarditis have been described recently in the literature.[1],[2],[3] Morbidity and mortality due to PPI infections are high unless aggressively managed. Uncommon organisms have occasionally been associated with PPI.[4] We report here a case of atypical mycobacteria isolated in a patient with PPI.

  Case Report Top

A 63-year-old man, who had been on a permanent pacemaker for few years, was referred to this hospital with complaints of fever and giddiness for past 3 months. The patient underwent pacemaker implant following complete heart block in 2002. The pacemaker generator was replaced in 2011 due to the end of life, (EOL is a term used to describe the battery condition of a used pacemaker).

Following replacement, it was observed that pacemaker pocket was infected. The generator was removed, sterilized, and reimplanted on the left side (infraclavicular). A few days later the patient developed fever and examination of the second site showed signs of infection (infection around the generator), that is, local pain and redness of the skin and purulent collection. Routine blood workup showed a total leukocyte count of 22,000 cells/cumm and C-reactive protein of 150 mg/L. Other systemic investigation was within normal limits, and all other laboratory parameters were normal. He was diagnosed as having infected pacemaker pocket (bilateral)[5] cardiac device-related endocarditis (CDE) (due to generator pocket infection).[6],[7] A temporary pacemaker was installed, and the permanent pacemaker generator was removed. Both pacemaker and the debrided tissue were sent for culture to the diagnostic microbiology laboratory. He was started on piperacillin + tazobactam 4.5 mg tid. Samples were inoculated into the brain heart infusion media.

As patient continued to have febrile episodes, antibiotics were changed to meropenem 1 g tid. As sepsis was suspected, one set of blood culture was sent. Blood culture flagged positive after the 5th day, and Gram-stain did not show any bacteria. Routine cultures did show any growth even after prolonged incubation. Anaerobic cultures were also negative.

As CDE was suspected multiple blood cultures (3 sets) were sent. After 6 days, subsequent blood cultures also flagged positive. As the organism was not growing on routine culture, fungal staining, and Ziehl–Neelsen staining was done from blood culture bottles which showed plenty of acid-fast bacilli [Figure 1].
Figure 1: Acid-fast bacilli seen in smear from blood culture bottle (Ziehl–Neelsen stain)

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As all of them grew mycobacteria within 10 days hence, a preliminary diagnosis of atypical mycobacteria (rapid growers) was made. Subcultures were done on LJ medium. The patient was started on rifampicin, INH, and ethambutol. After 9 days of inoculation, LJ medium showed pasty colonies. MPT64, was negative. So the organism was confirmed as nontuberculous mycobacteria. The pus from the pacemaker pocket also grew atypical mycobacterium [Figure 2]. As the patient was not responding to the primary drugs so clarithromycin, ofloxacin, and pyrazinamide was added.
Figure 2: Plenty of acid-fast bacilli seen in pus from pacemaker pocket (Ziehl–Neelsen stain)

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The isolate was identified as mycobacterium abscesses sensitive to quinolones, aminoglycosides, and clarithromycin. During hospital stay, he developed persistent neutropenia with thrombocytopenia. The patient developed deranged liver function test, so the dose of antitubercular treatment was adjusted accordingly. His condition continued to be critical. He had two episodes of cardiac arrest and could not be revived after 2nd episode.

  Discussion Top

CDE with atypical mycobacteria has occasionally been reported in PPI patients. In our case, the source could have been improperly sterilized pacemaker generator (we could not elicit a history of reuse battery) or failure to follow aseptic precautions during its insertion.

Blood cultures which appear as false positive due to no growth on conventional media, needs to be evaluated further by doing anaerobic cultures, fungal stains, and acid-fast staining as seen in this case. Early infections are most commonly caused by Staphylococcus aureus and late infections most commonly by Staphylococcus epidermidis, although infections by Staphylococcus lugudensis, Streptococcus bovis, mitis and sanguis, pseudomonas, enterococci, and fungi and even Mycobacterium fortuitum have been described. Discharge from insertion site inflammation or abscess, are more common than endocarditis and sepsis.

Treatment is always a challenge in these cases as identification of the infective organism, and the susceptibility pattern needs to the considered so as to have better outcome in these patients. Strict adherence to infection control protocols will prevent occurrence of such infections.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Ward M, Boehm KM. Pacemaker related infective endocarditis from Staphylococcus lugdunensis. Case Rep Crit Care 2013;2013:3.  Back to cited text no. 1
Voet JG, Vandekerckhove YR, Muyldermans LL, Missault LH, Matthys LJ. Pacemaker lead infection: Report of three cases and review of the literature. Heart 1999;81:88-91.  Back to cited text no. 2
Anguera I, Del Río A, Miró JM, Matínez-Lacasa X, Marco F, Gumá JR, et al. Staphylococcus lugdunensis infective endocarditis: Description of 10 cases and analysis of native valve, prosthetic valve, and pacemaker lead endocarditis clinical profiles. Heart 2005;91:e10.  Back to cited text no. 3
Kouvousis N, Lazaros G, Christoforatou E, Deftereos S, Petropoulou-Milona D, Lelekis M, et al. Pacemaker pocket infection due to Acremonium species. Pacing Clin Electrophysiol 2002;25:378-9.  Back to cited text no. 4
Kaul P, Adluri K, Javangula K, Baig W. Successful management of multiple permanent pacemaker complications – infection, 13 year old silent lead perforation and exteriorisation following failed percutaneous extraction, superior vena cava obstruction, tricuspid valve endocarditis, pulmonary embolism and prosthetic tricuspid valve thrombosis. J Cardiothorac Surg 2009;4:12.  Back to cited text no. 5
Edelstein S, Yahalom M. Cardiac device-related endocarditis: Epidemiology, pathogenesis, diagnosis and treatment – A review. Int J Angiol 2009;18:167-72.  Back to cited text no. 6
Gul EE, Kayrak M. Common pacemaker problems: Lead and pocket complications. In: Das MR, editor. Modern Pacemakers – Present and Future. InTech; 2011. Available from: http://www.intechopen.com/books/modern-pacemakers-present-and-future/commonpacemaker-problems-lead-and-pocket-complications. [Last accessed on 2015 Jun 10].  Back to cited text no. 7


  [Figure 1], [Figure 2]


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