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| CASE REPORT |
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| Year : 2015 | Volume
: 1
| Issue : 1 | Page : 57-59 |
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Atypical mycobacterial endocarditis in a permanent pacemaker implant patient
Ratna Rao, Ratna Mani
Department of Microbiology, Apollo Hospitals, Jubilee Hills, Hyderabad, Telangana, India
| Date of Submission | 11-Jun-2015 |
| Date of Acceptance | 15-Jul-2015 |
| Date of Web Publication | 9-Nov-2015 |
Correspondence Address:
Ratna Rao
Laboratory Director, Appollo Hospitals, Jubilee Hills, Hyderabad, Telangana
India
 Source of Support: None, Conflict of Interest: None  | Check |
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 |
| Introduction | |  |
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 | | |
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)
Click here to view |
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 | | |
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.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Ward M, Boehm KM. Pacemaker related infective endocarditis from Staphylococcus lugdunensis. Case Rep Crit Care 2013;2013:3.  |
| 2. | 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. |
| 3. | 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. |
| 4. | 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. |
| 5. | 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. |
| 6. | Edelstein S, Yahalom M. Cardiac device-related endocarditis: Epidemiology, pathogenesis, diagnosis and treatment – A review. Int J Angiol 2009;18:167-72. |
| 7. | |
[Figure 1], [Figure 2]
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