Device Infection Mimicry: Physical Examination Characteristics and Procedural Technique for Pacemaker-Associated Skin Cancer

•Pocket infection is a serious complication involving cardiovascular implanted electronic devices, typically managed with complete extraction of the device and leads.•It important to recognize that mimickers exist, which warrant different clinical management.•The physical examination can help distinguish true from other pocket infection, thereby direct appropriate management strategy.•It possible surgically address superficial skin processes over without entering itself, even when minimal subcutaneous fat present. One most complications pacemaker implantable cardioverter defibrillator implantation especially there are chronic indwelling leads would need be fully extracted. Identifying not always straightforward, as signs symptoms overlap those produced by non-infectious causes, such hematoma, allergic reaction, or neuropathy. Here we present case suspected an alternate diagnosis, highlighting enduring importance in era telemedicine health care. A 90-year-old man was referred for system due infection. dual chamber His-bundle ventricular lead had been 2 years earlier sinus node dysfunction markedly prolonged PR interval resulted pseudo-pacemaker syndrome. His quality life improved after implantation, healed well. few months prior presentation, patient noticed ulceration directly pocket. The failed heal, gradually became exophytic mass drained yellow, purulent fluid. local electrophysiologist started him on oral cephalexin consultation, forwarding photograph non-healing wound, immediately contiguous (Figure 1a). Blood cultures were negative, no fevers leukocytosis, reported systemic video consultation conducted rather than in-office visit because patient’s age, transportation barrier 3-hour commute, his responsibility caregiver at home wife dementia. Due chronic, wound pocket, along proximity surface, presumed. scheduled risks discussed, including possibility conduction injury removal pacing lead. reprogrammed locally VVI 30 ppm assess burden backup pacing, order anticipate post-extraction necessity timing reimplantation. On day presentation extraction, interrogation revealed less 0.1%, but feeling more fatigued since reprogrammed. function reasonable, native 450ms. examination, now crusted appearance, small rim erythema scant drainage 1b). Surprisingly, despite only thin layer tissue separating freely mobile upon manipulation, any adherence underlying (Video Data Supplement). There erythema, pain, warmth, fluid associated Because these findings, various procedural possibilities discussed patient, chance discovering process did involve system, obviate enter remove hardware. After informed consent all obtained, brought EP lab. generous amount 1% lidocaine infiltrated just deep lesion, serving purpose analgesia creating large wheal expand soft between An elliptical incision created blade around incorporating being cautious avoid excessive depth. Sharp dissection used undermine staying subdermal plane, excised specimen sent pathology 2a). Careful exploration exposed plane showed purulence, devitalized tissue, fistula tract. Instead, healthy, intact remaining evidence association communication itself 2b). Judicious electrocautery use achieve hemostasis, entered. area flushed antibiotic solution closed primarily absorbable suture 2c). final result received two weeks later, “squamous cell carcinoma lymphovascular invasion, completely excised, surgical margins free tumor.” Consultation dermatology confirmed further treatment needed. expected time frame recurrence tumor growth. Device infections commonly post-operative period, although long “tail” time, extending well beyond one year, procedures become manifest. presence swelling, cutaneous abnormalities should prompt broad differential diagnosis physician, bleeding, allergy, malignancy. Current HRS guidelines recommend cardiac (CIED) if infection/erosion, making it extremely accurately diagnose Many CIED series, retrospective analysis WRAP-IT trial,1Tarakji KG, Krahn AD, Poole JE, et al. Risk Factors Infection Secondary Procedures: Insights From Trial. JACC Clin Electrophysiol. Published online September 29, 2021. doi:10.1016/J.JACEP.2021.08.009Google Scholar show increased risk greater number procedures, therefore unnecessary avoided, particularly uncertain. ongoing Covid-19 pandemic circumstances mentioned above, this initially seen telehealth precluded opportunity perform planning. anticipated however, performed, revealing new critical observation lesion non-adherent leads. Skin described indicator infection2Kirkfeldt R.E. Johansen J.B. Nielsen J.C. Management Cardiac Electronic Infections: Challenges Outcomes.Arrhythmia Electrophysiol Rev. 2016; 5: 183https://doi.org/10.15420/AER.2016:21:2Crossref Google Scholar. This finding freely-moving raise independent process, dictate very operative strategy. Entering first step pose already present, given infectious milieu draining field. It note that, apparent nature still sub-dermal instillation anesthetic facilitate Cutaneous malignancy has mimicker requires awareness suspicion make correct manage problem appropriately 3Snorek M. Bulava A. Vonke I. Chronic lymphocytic leukemia infiltration mimicking ICD infection: report.BMC Cardiovasc Disord. 2017; 17https://doi.org/10.1186/S12872-017-0522-5Crossref Scholar, 4Milner J. Gonçalves F. L. many faces.J Cardiol cases. 2021; 24: 244-246https://doi.org/10.1016/J.JCCASE.2021.04.005Abstract Full Text PDF Scopus (0) 5Bodagh N. Pappa E. Farooqi Multidisciplinary team approach excision squamous overlying site.BMJ Case Rep. 2018; 2018https://doi.org/10.1136/BCR-2017-221660Crossref 6Tschabrunn C.M. Rosenbach Lavi Cooper J.M. Allergic reaction material procedure: mimicry.J 2012; 23: 330-332https://doi.org/10.1111/J.1540-8167.2011.02224.XCrossref highlights maintaining protect avoidable may delayed incorrect management. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3M2MzNTI4ZDUwOTJjMjNiZjgyMWQ2MThhOGE4MjNiMiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg5OTM0OTc3fQ.HajzunfgViRRVgSdGPUEHLA4bVlh5vx2qyKTXf3qIHPLoxW-Dl-RYkYvvjeOL4Sc1DrbtVwgKT14QgcZoCx-CjP6mwHncbXGPJhmRHHQQ5XRKVnHebcEA8B9NrtOOkxHZQs6HhYvmDPIvTkHSA81PaUqVgzoMx0A_NwxQEtapYv54dG2kXZYjlIgdRK3f5NJrpZS7I1Scjr9CPDkAQ4EuBJWa1IdzlCH3TZ2e2JEzAnApf4HctkcFVe229MkDYznmJbaBMb_IRir2T0h58mhNMBFDZPt-vA-YHOg3DbDHqlBwmF40gqk4gRbpYD0bEdfBBjFVK30nbbW8AMc_gSNiw Download .mp4 (1.26 MB) Help files .docx (.01 docx