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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 2  |  Issue : 1  |  Page : 82-84

Pacemaker site infection caused by Rapidly Growing Nontuberculous Mycobacteria (RGM)


1 Department of Microbiology, CARE Hospital, The Institute of Medical Sciences, Banjara Hills, Hyderabad, Telangana, India
2 Department of Cardiology, CARE Hospital, The Institute of Medical Sciences, Banjara Hills, Hyderabad, Telangana, India
3 Department of General Surgery, CARE Hospital, The Institute of Medical Sciences, Banjara Hills, Hyderabad, Telangana, India

Date of Web Publication5-Mar-2018

Correspondence Address:
Dr. Jhansi Vani Devana
CARE Hospital, The Institute of Medical Sciences, Banjara Hills, Hyderabad - 500 034, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bbrj.bbrj_6_18

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  Abstract 


There has been an increased use of cardiac pacemaker device utilization in cardiac patients with a corresponding increase of device-related infections in these patients. The common cause of postpacemaker implantation infection is either Gram-positive or Gram-negative bacteria. Infection of pacemaker implantation site due to nontuberculous mycobacteria is rare. Globally, thirty-two cases of pacemaker device infections caused by nontuberculous mycobacteria were reported. It is important to carry out not only species identification of mycobacteria but also drug susceptibility testing to start precise treatment to those patients, who are infected with atypical mycobacteria. We report a patient with pacemaker pocket infection due to Mycobacterium chelonae.

Keywords: Cardiovascular implantable electronic devices, non tuberculous mycobacteria, pacemaker site infection, rapidly growing


How to cite this article:
Devana JV, Calambur N, Reddy B R. Pacemaker site infection caused by Rapidly Growing Nontuberculous Mycobacteria (RGM). Biomed Biotechnol Res J 2018;2:82-4

How to cite this URL:
Devana JV, Calambur N, Reddy B R. Pacemaker site infection caused by Rapidly Growing Nontuberculous Mycobacteria (RGM). Biomed Biotechnol Res J [serial online] 2018 [cited 2020 May 28];2:82-4. Available from: http://www.bmbtrj.org/text.asp?2018/2/1/82/226578




  Introduction Top


Nontuberculous mycobacteria (NTM) have been identified in human pulmonary and extrapulmonary diseases. Prevalence of NTM infections in India is from 0.7% to 34%. A false diagnosis of NTM as tuberculosis poses a significant challenge to treat the patients.[1] Rapidly growing mycobacteria (RGM) include three clinically relevant species- (1) Mycobacterium fortuitum, (2) Mycobacterium chelonae, and (3) Mycobacterium abscessus. The clinical spectrum of diseases caused by RGM includes skin and soft tissue infections, surgical wound infections, and catheter-related infections. Other infections caused by RGM are prosthetic valve endocarditis and pulmonary infections. Reporting of RGM from surgical sites, pulmonary, and prosthetic devices has been increased recently. However, surgical site infection after pacemaker implantation due to NTM is very rare. Globally, the reported incidence of permanent pacemaker infection is between 0.3% to 12.6%.[2] Review of literature has revealed 23 cases of rapidly growing NTM infections in cardiovascular implantable electronic devices. We report a pacemaker pocket infection due to M. chelonae which has been successfully treated.


  Case Report Top


A 71-year-old male patient, known diabetic, hypertensive, was admitted with complaints of pain, swelling, and redness on the left upper chest wall. He underwent cardiac resynchronization therapy pacemaker (CRT-P) with a pacemaker implanted in the left upper chest wall 1 year back in another facility. On admission, he was afebrile. His pulse was 68/min and blood pressure was 130/80. Lungs are clear. On examination, a swelling on left upper part of the chest wall with erythema was noticed [Figure 1]. On palpation, induration and tenderness was observed on the infected site. The white blood cell count was 7000/mm3 and platelet count 77,000/mm3. Blood culture was negative. The patient has undergone TPI and extraction of the pulse generator and leads. Approximately 10 ml of pus was collected and sent for AFB stain and cultured. AFB stain showed Acid-fast Bacilli [Figure 2]. A growth was seen in Blood Agar plate after 6 days of incubation, [Figure 3] and the organism was identified as M. chelonae. In view of persistent low-grade fever and thrombocytopenia, CRT-P procedure was postponed for few days. After symptomatic improvement and due to financial constraints, same pulse generator was reinserted in opposite side of chest wall after ethylene oxide (ETO) sterilization and discharged with empirical antibiotic therapy. Three months after reimplantation of the device, the patient presented with similar complaints in the right upper chest wall [Figure 4] which was removed again and a permanent pacemaker was kept. Treatment was initiated as per se nsitivity pattern. The patient improved symptomatically and discharged. He is on regular follow-up, and there is no recurrence of infection.
Figure 1: Swelling over the left upper chest wall

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Figure 2: Ziehl Neelsen staining from the pus

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Figure 3: Nontuberculous mycobacteria growth in the blood agar plate

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Figure 4: Swelling over the right upper chest wall

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  Discussion Top


RGM species are ubiquitous environmental organisms that have been isolated from soil, food, natural and municipal water, and hospital surfaces. Their optimal incubation temperature ranges from 25°C to 40°C and is characterized by rapid growth (within 7 days) and can be misinterpreted as Corynebacterium or Nocardia. They are able to survive in harsh conditions and can produce biofilms in aquatic environments such as pipes and water systems from which large clumps of mycobacteria are released and cause infections in humans.[3] These organisms can grow on standard mycobacterial media such as Middlebrook 7H11, LJ media and on bacteriological media such as MacConkey, sheep blood agar, etc., In contrast to mycobacterium tuberculosis, there is no systematic reporting of NTM infections and there is no epidemiological data on NTM infections since NTM infections are not reported to public health departments. Jesudason and Gladstone reported an incidence of 3.9% NTM infections in various samples.[4] More than half of the infections were caused by M. fortuitum. Only two cases of M. abscessus were reported as etiological agents for cardiovascular implantable electronic devices infections.[5] In India, there is sporadic reporting of pacemaker infections due to NTM. Our patient had deep surgical site infection which required extraction of pacemaker and wound debridement. Due to financial constraints of the patient, the same pacemaker was reimplanted in the opposite chest wall after ETO sterilization. However, the infection recurred which required removal of the pacemaker from the second site also. There are several reports of reusing pacemakers explanted after death with satisfactory results. However, reuse of infected pacemaker is not recommended as NTM is resistant to most of the routine sterilization methods. This was proved in our case. Even though the device was sterilized with ETO, the patient developed infection. Hooda et al. reported a disseminated M. chelonae infection causing pacemaker lead endocarditis in an immunocompetent host.[6] Bharat et al. reported an outbreak of pacemaker pocket infection due to environmental mycobacteria.[7] Reporting of this unusual organism at the unusual site is usually delayed because of low index of clinical suspicion.


  Conclusion Top


NTM infection at pacemaker site is very rare. They should be thought of in case of recurrent infection or delayed wound healing for more than a week. With increasing incidence of NTM infections in the pacemaker site, it would be worth considering these organisms as emerging pathogens in device-related infections.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Umrao J, Singh D, Zia A, Saxena S, Sarsaiya S, Singh S, et al. Prevalence and species spectrum of both pulmonary and extrapulmonary nontuberculous mycobacteria isolates at a tertiary care center. Int J Mycobacteriol 2016;5:288-93.  Back to cited text no. 1
  [Full text]  
2.
Samanta RP, Babu GV. Mycobacterium tuberculosis infection at pacemaker implantation site. J Assoc Physicians India 2017;65:88-9.  Back to cited text no. 2
    
3.
Piersimoni C, Scarparo C. Extrapulmonary infections associated with nontuberculous mycobacteria in immunocompetent persons. Emerg Infect Dis 2009;15:1351-8.  Back to cited text no. 3
    
4.
Jesudason MV, Gladstone P. Non tuberculous mycobacteria isolated from clinical specimens at a tertiary care hospital in South India. Indian J Med Microbiol 2005;23:172-5.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Phadke VK, Hirsh DS, Goswami ND. Patient report and review of rapidly growing mycobacterial infection after cardiac device implantation. Emerg Infect Dis 2016;22:389-95.  Back to cited text no. 5
    
6.
Hooda A, Pati PK, John B, George PV, Michael JS. Disseminated Mycobacterium chelonae infection causing pacemaker lead endocarditis in an immunocompetent host. BMJ Case Rep 2014;2014 pii: bcr2014206042.  Back to cited text no. 6
    
7.
Bharat V, Hittinahalli V, Mishra M, Pradhan S. Pacemaker pocket infection due to environmental mycobacteria: Successful management of an outbreak and steps for prevention in future. Indian Heart J 2016;68:63-7.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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