Case
70 year old male with recent history of a non-ST elevation myocardial
infarction with cardiac arrest status post two vessel coronary artery
bypass grafting with course complicated by sustained ventricular
tachycardia leading to leading to CIED placement (dual chamber
implantable cardioverter-defibrillator with pacemaker function)
presented to the hospital with complaints of redness at the site of his
insertion pocket one month after implantation. There was also some
purulent drainage from the insertion site few days prior to
presentation. He did not have any fevers or chills. Upon presentation to
the emergency department, the vital signs revealed a heart rate of 79
per minute, respiratory rate of 20 per minute, blood pressure of 125/79
mmHg, oxygen saturation of 97% on room air, and temperature of 97.5°F.
Physical exam was significant for erythema at the CIED insertion site
with tenderness to palpation and expression of yellow purulence.
Cultures were sent from the emergency department. Laboratory data showed
normal white cell count of 5100 per microliter, and mild
thrombocytopenia with platelet count of 121,000 per microliter. The
remainder of the laboratory results were normal. The human
immunodeficiency virus test was negative.
Chest X-ray showed intact CIED leads without any acute abnormality. He
was empirically started on intravenous vancomycin and cefazolin.
Transthoracic echocardiogram was negative for vegetations on the native
valves. Cardiology was consulted and the device including the leads were
subsequently removed with wound cultures obtained. During the procedure,
copious amount of purulent drainage was noted. Gram stain showed
moderate white blood cells without any organisms. The remainder of his
clinical course was uncomplicated without any systemic signs of
infection and blood cultures remaining negative. He was thus discharged
with a life vest and was prescribed doxycycline with outpatient
infectious disease follow up. During follow up the cultures were growingM. fortuitum and he was thereafter started on levofloxacin and
clarithromycin. This was eventually changed to levofloxacin and Bactrim
after susceptibility results were available (Table 1) . He was treated
for 4 months and the infection resolved.
However, at one of his follow up visits 5 months later, he was noted to
have tenderness, redness, and swelling of his left chest wall again. An
ultrasound was ordered which showed a possible pocket of abscess
collection, approximately 4.7 x 3.0 cms in size, and he was subsequently
admitted to the hospital. He was empirically started on vancomycin and
ceftriaxone, and repeat blood cultures were sent. The patient was then
taken to the operating room for incision & drainage (Figure 1) and
wound cultures were obtained. Considering his recurrence and based on
prior antibiotic susceptibilities, the patient was discharged on Bactrim
and linezolid. However, he developed pancytopenia that was attributed to
linezolid, he was switched to a combination of Ciprofloxacin and
Bactrim. His wound cultures grew M. fortuitum this time as well
and he was able to complete his antibiotics without further
complications. He was eventually seen in the clinic, for a follow up at
a six-month follow-up and deemed to be infection-free based on clinical
symptoms, and eventually was able to get a CIED placement on his right
side.