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.