AGMR Annals of Geriatric Medicine and Research

2016;20(4):229-232
https://doi.org/10.4235/agmr.2016.20.4.229
Print ISSN 2508-4798 On-line ISSN 2508-4909
C a se R e p o rt www.e-agmr.org

Drug Fever in an Elderly Patient After Pacemaker

Implantation
Dong Wook Lee, Ju Hee Ha, Jun Ho Kim, Ki Beom Park, Jae Joon Lee, Han Il Choi, Jin Hee Kim

Department of Internal Medicine, Busan Medical Center, Busan, Korea

Corresponding Author: Jin Hee Kim, MD
Division of Cardiology, Department of Internal
Medicine, Busan Medical Center, 359
Wordcup-daero, Yeonje-gu, Busan 47527, Korea
Tel: +82-51-507-3000, Fax: +82-51-507-3001
E-mail: yoplait83@hanmail.net
Received: July 26, 2016
Revised: October 11, 2016
Accepted: October 17, 2016
Pacemaker implantation-related infective endocarditis is an uncommon, but
serious complication. The estimated incidence of infection after permanent endo-
cardial pacemaker implantation varies from 0.2% to 3%. Infective endocarditis
shows a mortality rate of 30% to 35%. Conservative medical treatment without
removing the pacemaker is prone to failure, and reinfection rates of 51% to
77% have been noted in patients whose pacemaker systems become infected.
Therefore, diagnosis of the primary infection is particularly important because
surgical removal of the pacemaker system is usually required for its treatment.
We describe here an 80-year-old woman who had drug fever that could have
been misdiagnosed as infective endocarditis after pacemaker implantation.

Key Words: Pacemaker implantation, Drug fever, Infective endocarditis

partment of Busan Medical Center as an outpatient with

INTRODUCTION
Pacemaker implantation is a relatively safe procedure with
few complications, which is commonly performed to treat
patients with cardiac arrhythmia1). Infective endocarditis in-
volved in an implanted intracardiac electrode is reported
to occur, on average, in 0.5% of patients with a pacemaker,
although different studies have reported different occur-
rence rates2). Although infective endocarditis rarely occurs
in patients with a pacemaker, when it occurs, it is a very serious
complication that can be fatal and is difficult to diagnose3).
A diagnosis of infective endocarditis is typically made by
observing clinical patterns, blood culture results, and echo-
cardiograms of cardiac vegetation; however, transthoracic
echocardiography findings are unclear in the case of endo-
carditis involved in an electrode. In most cases, treatment
requires surgical removal of the electrode causing the in-
fection; thus, accurately making a diagnosis is especially
important4). In this case study, we report a case in which
drug fever following pacemaker implantation could have been
misdiagnosed as infective endocarditis; we additionally re-
viewed the relevant literatures.
CASE REPORT
An 80-year-old female patient visited the cardiology de-
primary complaints of breathing difficulty and dizziness dur-
ing physical exercise, which had started a month previously
and were gradually worsening. She had a history of hyper-
tension and asthma and was taking drugs to treat them.
She had no history of smoking or drinking and no family
history of heart disease. Regarding her vital signs, blood
pressure was 100/60 mmHg, pulse was 34 beats/min, respira-
tion was 20 breaths/min, and body temperature was 36.0℃.
Thus, bradycardia was observed, and complete atrioventri-
cular block was found on electrocardiogram (Fig. 1A). After
it was confirmed that none of the drugs she was taking
caused the condition, a pacemaker was implanted (Fig. 2).
Following the implant and confirmation that her systemic
condition and the condition of the surgical area were good
and her heart rate was well controlled, she was transferred
to the general ward for observation (Fig. 1B). Prophylactic
antibiotic therapy, ceftriaxone (2 g daily) was administered
for 8 days starting a day before the procedure, after which
fever, chills, and weakness were observed. There was no
jugular vein distention, her breathing sounds were normal,
and her heart sounds were regular without cardiac noise.
The abdomen was soft and smooth without tenderness, and
there was no palpable mass. There was no abnormality in
limb mobility or pitting edema. An electrocardiogram showed
that the heart pulsated by the pacemaker, and simple chest
radiographs did not show any abnormalities such as car-

Copyright © 2016 by Korean Geriatric Society

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/)
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Dong Wook Lee, et al.

Fig. 1. (A) Initial electrocardiogram on admission showed complete absence of atrioventricular conduction. (B) The electrocardiogram
after pacemaker implantation showed a paced rhythm with a small spike.

diomegaly or pulmonary congestion.

Fig. 2. Chest radiograph
after pacemaker implanta-
tion.
Fig. 3. Transthoracic echocardiography shows no definite vegeta-
tion attached to the pacemaker leads in the right atrium and
right ventricle. (A) Apical 4-chamber view. (B) Subcostal view.
On peripheral blood testing, the patient’s white blood cell
count was 11,800/mm3 (polymorphonuclear leukocytes 78%),
her hemoglobin level was 11.5 g/dL, and her platelet count
was 154,000/mm3. She had an elevated C-reactive protein
(CRP) level (35.62 mg/L) but normal creatine kinase-MB (2.8
ng/mL) and troponin I (0.005 ng/mL) levels. Additionally, liver
and kidney function and urine tests revealed no notable
findings.
On transthoracic echocardiography, a pacemaker elec-
trode, but no vegetation, was seen in the right atrium and
the right ventricle (Fig. 3). Pathogens were not detected on
the wound swab or on blood cultures repeated 3 times.
Fever and chills were observed, and skin flare-ups and pruritus
were spread over the upper body, including the face and
neck, in addition to local flare-ups around the area of the
pacemaker implant (Fig. 4). In the beginning, infective endo-
carditis was suspected based on the clinical observations.
However, a bacterial culture test and echocardiography, i.e.,
the primary diagnostic standards for infective endocarditis,
returned negative results and there was no other severe
or systemic symptoms. Thus, we considered the possibility
of drug fever because of the accompanying flare-ups and
hypereosinophilia, and switched the prophylactic antibiotic
therapy. Subsequently, the patient’s condition improved re-
garding the skin lesions, fever, and chills, and she was dis-
charged. Currently, she has shown no notable findings and
is being followed up as an outpatient.

DISCUSSION
Since approximately 30 years ago, when a pacemaker was
implemented for the first time, the use of permanent pace-
makers and defibrillators has increased with the aging of
the population and the expanded clinical indications. Accor-
dingly, complications related to the procedure are often
encountered in practice. Infection due to an intracardiac
electrode rarely occurs after pacemaker implantation, but
if it does, the complication can have fatal consequences.
Fig. 4. Skin lesion of The occurrence rate is reported between 0.5% and 7% depen-
chest and neck. ding on the study5), and the mortality rate of infective endocar-

230 www.e-agmr.org

ditis due to pacemaker implantation is approximately 30%-
6)
50% .
Most infections that occur immediately following pace-
maker implantation are known to be caused primarily by
local contamination of the electrode catheter due to the
lack of aseptic processing control at the time of implantation,
with the common pathogen being Staphylococcus aureus7).
Therefore, it is crucial to minimize local contamination factors
while performing the procedure.
The main difficulty in diagnosing infective endocarditis
related to an intracardiac electrode is the lack of clearly
established diagnostic standards. Typically, a diagnosis of
infective endocarditis is made if pathogens are detected
on a blood culture or vegetation is confirmed on an echo-
cardiogram8). In addition, when a blood test shows an eleva-
tion in inflammatory indices such as the complete blood
count (CBC), erythrocyte sedimentation rate, or CRP level
in conjunction with such symptoms as flare-ups and pain
in the area of pacemaker implant, fever, chills, and systemic
weakness, a link with infective endocarditis should be con-
sidered.
If a diagnosis of infective endocarditis is confirmed or
infective endocarditis due to pacemaker implantation is
strongly suspected based on several clinical signs and symp-
toms, all involved parts should be removed at an early stage.
A new pacemaker should be implanted in another area after
a certain amount of time has passed only in cases where
a pacemaker is inevitable. Recently, it has been reported
that the condition improved with single-antibiotic therapy,
but most studies recommend early removal of the pacemaker
as the standard treatment in all cases. Practically, there
are marked differences, by severalfold, between conservative
and surgical treatments in treatment success rates and
in-hospital and overall mortality rates9).
When an artificial object such as a pacemaker, catheter,
artificial heart valve, or artificial joint is implanted in the
human body, biofilms are formed composed of substances
such as fibrin and collagen from the object’s surface or
the surrounding area of the body and glycocalyx from the
pathogens. Once the pathogens form colonies on the biofilm
around the artificial part, it functions as a protective mem-
brane against the neutrophils, macrophages, and antibodies
of the host. So, if treated only with antibiotics, the strength
of the antibiotics needs to be 100 times higher than standard
antibiotic therapy, and ultimately, the removal of the artificial
part is essential to overcome it10).
The patient reported in this case study showed clinical
symptoms of fever accompanied by local flare-ups around
the surgical area, chills, and other symptoms after pacemaker
implantation; an elevation in inflammatory indices such as
CBC and blood CRP level was also found. As in the current
case, being an older female and the use of steroids to treat
Drug Fever After Pacemaker Implantation
asthma can be crucial risk factors for infection related to
pacemaker implantation. The possibility of pacemaker-rela-
ted infective endocarditis could have been considered in
this situation; however, pathogens were not detected on
bacterial cultures and no vegetation was observed on an
echocardiogram, which are the major diagnostic standards
for infective endocarditis. In the current case, the primary
diagnostic standards according to the Duke criteria (widely
used to make a diagnosis of infective endocarditis) were not
all met; among the secondary diagnostic standards, only one
criterion of fever above 38℃ was met. Although the clinical
evaluation of fever was unclear, the patient's recovery course
was not serious and overall stable; she had fever accompanied
by flare-ups, hypereosinophilia detected through a blood
test, and skin lesions accompanied by pruritus spreading
to the overall upper body including the face and neck. Thus,
we determined that drug fever was a possibility and switched
the prophylactic antibiotic that she had been on, after which
her systemic symptoms such as periodically occurring fever
and chills and skin flare-ups improved.
As reported above, it is difficult to diagnose infective
disease involved in an intracardiac electrode, and a misdiag-
nosis can even lead to an unnecessary surgery. Therefore,
if a patient with a pacemaker shows an ambiguous clinical
pattern and the findings of blood cultures and echocardiog-
raphy are unclear, the physician should consider various
causes including drug fever to increase diagnostic accuracy
and prevent unnecessary surgery.
Drug-related allergy occurs due to immunological mecha-
nisms and is characterized by a history of exposure to a
suspected drug and hypersensitivity even to a small amount
after sensitization and reproducibility. Elderly patients are
more likely than younger patients to have already been expo-
sed to multiple medications; therefore, the possibility of drug
allergy should be considered in diverse treatment situations
in which fever or skin lesions occur.
Conflicts of Interest Disclosures: The researchers claim
no conflicts of interest.
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