Cardiac Device Infections due toMycobacterium fortuitum

Abstract

Two cases of cardiac device infection due to Mycobacterium fortuitum are reported along with a discussion of their clinical management. Long-term therapy and removal of the infected device is needed. The slow progression and absence of systemic signs and symptoms suggest a low pathogenicity of M fortuitum. M ycobacterium fortuitum is a rapidly growing mycobacteria that is ubiquitous in soil and water. It is an opportunistic pathogen, and usually causes skin, skeletal or catheter-related infections (1,2). To date, no cases of M fortuitum infection of pacemakers or implantable cardioverter defibrillators have been reported. CASE PRESENTATIONS Case 1A 72-year-old man with a history of diabetes mellitus type 2 and hypertension had a pacemaker implanted in December 2000 for sinus node disease. Two weeks later, a surgical site infection with abscess formation at the site of pacemaker implantation was observed. The abscess fluid grew a coagulasenegative staphylococcus, which was treated with ciprofloxacin over four weeks. M fortuitum was also isolated, but was interpreted as a possible contamination. One year later, the patient was hospitalized for 11 days for exploration of the pacemaker site due to subcutaneous nodules and chronic drainage. He developed a postoperative fever, but blood cultures were negative. Parenteral teicoplanin and ceftriaxone were administered for three weeks. Two months later, treatment with ciprofloxacin, trimethoprim-sulfamethoxazole and clarithromycin was started and then changed to amikacin and ciprofloxacin once the antimicrobial susceptibility pattern for the isolated M fortuitum was available. Susceptibility testing was performed in the clinical microbiology laboratory with the agar disk elution method for amikacin, tobramycin, ciprofloxacin, doxycycline, cefoxitin, imipenem and trimethoprim-sulfamethoxazole, and by a disk diffusion method for clarithromycin, azithromycin, erythromycin and tetracycline. The isolate was susceptible only to amikacin and ciprofloxacin. Ceftriaxone was not tested. All subsequent cultures remained sterile, but the patient was again hospitalized for 23 days for pacemaker removal. Further postoperative fever delayed the implantation of a new pacemaker by 14 days. An echocardiography showed no vegetations. Ciprofloxacin was continued for six months after pacemaker replacement, and amikacin was discontinued after 15 days due to injection site problems and the development of hearing impairment. At three years follow-up, the patient was well with no evidence of recurrence. Case 2A 61-year-old man had an implantable cardioverter defibrillator in July 2000 for severe coronary artery disease and multiple episodes of ventricular tachycardia. At routine follow-up in December 2001, he presented with evidence of a cutaneous infection overlying the generator. M fortuitum was isolated from culture. Treatment with ciprofloxacin was initiated but

Microbiology and Pathogenesis of Cardiovascular Implantable Electronic Device Infections

“…71 However, unusual organisms such as mycobacteria and Aspergillus species have also been described in isolated case reports. [72][73][74][75] The role of local skin flora at the time of device implantation were explored in a study by Da Costa et al, 76 who collected culture specimens from the site of implantation before and after device insertion in 103 consecutive patients who underwent elective PPM implantation. During a mean follow-up of 16.5 months, infection occurred in 4 (3.9%) patients.…”

Fortuitous Vasculitis

“…14 15,16 A pacemaker pocket infection was present in all cases; half had accompanying systemic features, five (42%) had involvement of the pacemaker leads, five (42%) had bacteremia, and one patient (8%) had myocardial abscess. Only one patient had a lead-tip vegetation from which AAFB were identified.…”

Cardiac implantable electronic device infection due to Mycobacterium species: a case report and review of the literature

“…The infection occurred between 8 days and 20 years from the last device related procedure. It occurred with both transvenous [ 17 , 18 , 20 – 22 , 24 – 27 , 30 , 31 , 33 – 39 ] and epicardial device implantations [ 19 , 23 , 28 , 29 , 32 ]. Mycobacterium tuberculosis was reported in seven cases [ 18 , 23 , 28 , 31 , 36 ] with mostly pocket infection.…”