DESCRIPTIONIn December 2011, an 83-year-old thin woman was referred to our emergency department because of 'a thoracic cutaneous abnormality'. In 2001, a permanent pacemaker had been implanted due to symptomatic sick sinus syndrome. Since then, she had remained well. Thirteen days before admission, a routine control assessment performed at pacemaker clinic displayed clinical and electrical normal fi ndings. On admission, physical examination was remarkable for the presence of two lesions in the skin lied just above the generator ( fi gure 1 ). The fi rst was ulceration with slight perilesional erythema and the second consisted on isolated erosion which let us directly see the generator. White cell blood count and erythrocyte sedimentation rate were within normal limits and blood cultures were negative. Complete device removal, pocket cleaning and closure, and reimplantation of a new pacemaker on the left-sided subpectoral region were carried out. As there were signs of pocket infection only, she was on antibiotic therapy for 14 days. Outcome was favourable. With an increasing number of indications for implantation of cardiac devices and considering that incidence rates of cardiac device infections usually range from 0.13% to 19.9% for permanent pacemaker, 1 clinicians can have the possibility to deal with this kind of condition in their common practice. Although ulceration of foreign bodies is not unusual, pacemaker infection presented as skin ulceration and erosion seems to be a rare event. 1 2 The pathogenesis of these disorders may include local infection and continuous pressure of the hard device against the overlying subcutaneous and cutaneous structures, 1 2 with ensuing development of tissue ischaemia and necrosis (like occur in other pressure ulcer cases). 3 Besides subsequent infectious complications, device erosion can result in loss of pacing. 4 Cure of cardiac device infections is possible in most patients with an approach that involves device extraction and antimicrobial therapy. 1,2 4Competing interests None. Patient consent