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Nontuberculous mycobacteria (NTM) first gained widespread attention as a cause of opportunistic infection, namely by Mycobacterium avium complex. For the last several decades, however, other NTM species have been increasingly identified as important pathogens behind both nosocomial and community-acquired disease. Since the 1990s, sporadic case reports of NTM infections of cardiac implantable electronic devices (CIEDs) have appeared. These represent approximately 0.2% of CIED infections, but have important clinical consequences. We present a case of CIED infection with Mycobacterium abscessus, which, to our knowledge, is only the third reported case in the literature.

A 63-year-old male presented to our emergency department with a three-day history of increased drainage from the site of his pacemaker extraction, performed nine days prior due to infection. Wound cultures taken during surgery were positive for Mycoplasma[SJ1] Mycobacterium abscessus and Staphylococcus epidermidis and he was initially treated with linezolid and sulfamethoxazole-trimethoprim. Past medical history included sick sinus syndrome for which the pacemaker was placed, daily intravenous heroin use, and chronic hepatitis C. Exam revealed normal vital signs and an incision in the left upper chest with interrupted sutures in place and surrounding induration and mild erythema. Initial labs were significant for acute kidney injury, negative blood cultures, and pancytopenia felt to be secondary to his hepatitis C. Ultrasound imaging showed a large, multiseptated fluid collection, and fluid aspiration grew Mycobacterium abscessus. Empiric vancomycin, cefoxitin, clarithromycin, and amikacin were started. . Multiple cardiac imaging studies showed thrombi thought to be secondary to pacemaker removal but no vegetations. In conjunction with the National Jewish Health Division of Mycobacterial and Respiratory Infections, a treatment plan was developed for a two-month induction phase with amikacin, cefoxitin, and clarithromycin followed by a 12-month maintenance phase with clarithromycin and clofazimine, the latter of which was obtained after IRB and the Food and Drug Administration (FDA) approval. Further debridement of the wound was deferred after consultation with multiple surgeons. At follow-up two months later, the patient was doing well with good healing of his surgical site and no new symptoms. This case highlights some of the unique qualities and challenges of NTM infections. Though ubiquitous worldwide in soil and water, NTM infection is uncommon and detection requires a high index of suspicion. Treatment is complicated by unpredictable resistance patterns, a need for compliance with up to year-long antimicrobial medications, and thoughtful evaluation of the use of arrhythmogenic drugs in patients with removed CIEDs. Finally, it describes a rare manifestation of extrapulmonary (or cardiac?) Mycobacterium abscessus disease.

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