Necrotizing fasciitis secondary to the insertion of a cardiac pacemaker

Abstract

We present, to our knowledge, the first reported case of necrotizing fasciitis following insertion of a cardiac permanent pacemaker (PPM). A 91-year-old gentleman was admitted with septic shock under the medical team. He had had a cardiac PPM inserted 10 days prior for complete heart block. He was initially treated by the GP for a postoperative superficial infection with a course of oral antibiotics at home but over the next few days he became systemically unwell. Preadmission, this patient was independent, living with his wife and had no other significant past medical history apart from the heart block. On admission he had suffered a ventricular tachycardia-related cardiac arrest and had been successfully resuscitated. He was subsequently managed in the coronary care unit (CCU) with a diagnosis of systemic sepsis from an infected pacemaker. While in CCU his condition deteriorated and he developed acute renal failure. It was noted that the cellulitis was becoming increasingly widespread around the pacemaker site, and was not responding to the intravenous antibiotics. There was an extremely high suspicion of necrotizing fasciitis, and the plastic surgeons were contacted for a review. The same day, he was expeditiously taken to theatre by the plastic surgical team. Perioperative findings included the presence of murky fluid, oedema of the subcutaneous tissue and necrotic muscle around the pacemaker. This gentleman then underwent a radical debridement of the infected tissues. The infected pacemaker was removed and the patient temporarily externally paced. Microbiology revealed the causative organisms to be Staphylococcus capitis, Streptococcus salivarius and Staphlococcus aureus. The histology from the samples gathered at the time of the procedure was consistent with a diagnosis of necrotizing fasciitis. Following treatment in the intensive care unit, the open chest wound was closed with a split thickness skin graft, five days post-debridement. He had re-implantation of a new PPM on the contralateral (right) side two days later.