Po-02-059 inflammatory reaction to antibiotic eluting pouch masquerading as recurrent cardiac implantable electronic device infection

Absorbable antibacterial envelopes mitigate risk of pocket infections during repeat cardiac implantable electronic device (CIED) procedures. Despite use of antibacterial envelopes, risk of CIED infection persists. However, hallmark signs of CIED infection including incisional erythema, drainage, and wound dehiscence overlap with a less common clinical entity – allergic reaction. To present a case of recurrent CIED wound dehiscence secondary to an inflammatory response to the antibacterial envelope proven with histological evaluation. N/A A 52-year-old male with remote aortic valve replacement complicated by complete heart block and a dual chamber pacemaker (DC PPM) underwent generator change with use of a Tyrx antibacterial pouch. One week later, he developed partial wound dehiscence and cloudy incisional drainage. The patient was started on antibiotic therapy and underwent percutaneous system extraction with placement of an externalized right ventricular lead. Pocket cultures were negative. A contralateral DC PPM was inserted with a Tyrx pouch. The patient completed a course of antibiotics. Within two weeks of placement, he presented with recurrent wound dehiscence. The new device was removed with a pathologic specimen obtained from the presumably infected pocket and an externalized pacing lead was placed. Cultures were again negative. The pathologic specimen demonstrated foreign body response with lymphoplasmacytic and focal neutrophilic inflammation most consistent with allergic reaction. The patient underwent implantation of a low-lateral left-sided DC PPM distant from the prior site without the use of a Tyrx antibacterial envelope. The patient was discharged without antibiotics with no evidence of infection or inflammation at the new site over a follow up period of 6-months. Allergic reaction to Tyrx antibiotic envelope should be considered with wound dehiscence, particularly if recurrent. Tissue biopsy with foreign body response can elucidate an allergic mechanism.