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J Thorac Cardiovasc Surg 2005;130:937-938
© 2005 The American Association for Thoracic Surgery
Brief Communication |
a Cardiologie Pédiatrique, Hôpital Necker-Enfants Malades, Paris, France
b Laboratoire de Bactériologie-Virologie-Parasitologie, Hôpital Necker-Enfants Malades, Paris, France
c Service des Maladies Infectieuses et Tropicales, Hôpital Necker-Enfants Malades, Paris, France
Received for publication April 4, 2004; accepted for publication April 21, 2004. * Address for reprints: Phalla Ou, MD, Service de Cardiologie Pédiatrique, Hôpital Necker-Enfants Malades, 149 rue de Sèvres 75743, Paris Cedex 15, France (Email: phalla.ou{at}nck.ap-hop-paris.fr).
Pacemaker infection with Mycobacterium tuberculosis has not been reported previously. We describe a case of pacemaker infection with M tuberculosis in an 8-year-old patient in a country in which tuberculosis is not endemic.
Clinical Summary
An 8-year-old patient had been followed up at our institution for a congenital cardiac malformation with a single-ventricle physiology. After multiple cardiac surgical interventions, an epicardiac pacemaker was implanted during cavopulmonary arterial anastomosis surgery for a complete atrioventricular block when the patient was 6 years old.
After a symptom-free interval of 11 months, the patient was seen with a subcutaneous abscess of the pacemaker site. The pacemaker was surgically removed, although only three of the four leads could be removed because one had integrated entirely into the myocardium. Bacteriologic cultures of the surgically removed material remained sterile. After 5 weeks of probabilistic intravenous antibiotic therapy, a new epicardiac pacemaker was implanted at a different site.
Six months later, the patient was seen with decreased general health, moderate fever, and inflammatory syndrome. A battery of blood cultures yielded negative results. Echocardiography did not find any evidence of endocarditis. While awaiting more specialized investigations, we observed a subcutaneous lump above the new pacemaker site. The abdominothoracic computed tomographic scan (Figure 1) showed the typical aspect of a soft-tissue abscess, containing the pacing wires and accompanied by an inflammation following the wire pathway. After complete drainage and surgical ablation of the pacemaker, acid-alcohol–resistant bacilli were found on Ziehl-Neelsen stain, and the diagnosis of M tuberculosis was confirmed by IS6110-based polymerase chain reaction assay and by culture of the surgically drained fluid and pacemaker leads. The Mantoux test showed a positive reaction in the bacille Calmette-Guérin–vaccinated patient, who had never been in a country in which tuberculosis was endemic. Results of Mantoux tests and chest radiographs of the 5 members of the patient's direct household who were of North African origin but resident in France remained negative. Microbiologic investigations of a potential origin of the infection in our institution also yielded negative results.
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A quadruple treatment with rifampin (INN: rifampicin), isoniazid, ethambutol, and pyrazinamide for 2 months was followed by double therapy (isoniazid and rifampin) for another 7 months. The strain was susceptible to the 4 antituberculosis drugs. The patient has had good clinical progress with the antituberculosis treatment, but the implantation of a new pacemaker was delayed for several months to prevent recurrence of the infection.
Discussion
Recurrent and chronic infection of a pacemaker site is a frequent complication once a first infection has occurred. The incidence is higher in the pediatric population and increases with the number of changes of the pacemaker.
1
Complete surgical removal of the pacing material is therefore considered to be the most effective treatment.
1-3
Identification of the infectious agent is crucial to target the antibiotic treatment. In 40% of infected patients, staphylococci are detected in bacteriologic cultures, whereas in 40% of surgically removed pacing leads, no infectious agent is found.
2,3
Pacemaker infections by mycobacterial species other than M tuberculosis are rare but well documented.
4,5
To our knowledge, this is the first case of a pacemaker infection with M tuberculosis. The source may have been among the visitors from the North African origin of the family, where tuberculosis is endemic, but we were unable to investigate. Our case report emphasizes the importance of considering mycobacteria in pacemaker infections, particularly when Gram staining or standard cultures yield negative results.
However rare, pacemaker infection with M tuberculosis must be considered in a patient with a chronic infection, particularly when Gram stain or standard culture results are negative. This is especially true for patients with a family background from a high-burden country.
References
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