The clinical presentations of cardiovascular implantable electronic device (CIED)-related infection can be broadly categorized into two groups: generator pocket infection and endovascular infection with an intact pocket [3,4]. The risk of device infection is estimated to be approximately 2% at 5 years after implantation [5]. About 60 – 80 % of infections are caused by either Staphylococcus aureus or coagulase-negative staphylococci. A variety of other bacteria and fungi are less commonly identified as causes of CIED infection [6,7]. Findings at the pocket site that are suggestive of infection include purulence, inflammatory changes, gelatinous material, loss or thinning of subcutaneous tissue, and poor capsule formation. Blood cultures are recommended in all suspected cases of infection, regardless of whether the patient is febrile or has other signs or symptoms of systemic infection. Blood samples should be drawn from different sites for at least two sets of cultures [8]. However, blood cultures may be negative despite infection, particularly in patients with pocket-site infection and in those given antibiotics shortly before blood samples are obtained for culture. It has been suggested that deep tissue specimens at the pocket site and lead tips should be obtained and cultured. In our case, these were obtained and when subjected to culture confirmed the diagnosis of infection with Brucella melitensis. The microorganisms that cause CIED infections may be acquired either endogenously from the skin of patients or exogenously from the hospital inanimate environment or from the hands of hospital workers. In support of endogenous acquisition, an association has been noted between the presence of preaxillary skin flora and the pathogens isolated from pacemaker infection8. Brucella infection of prosthetic materials including prosthetic joints, prosthetic valves, and ventricle septal defect patch has been reported [9,10]. Though Brucella species are primarily intracellular pathogens, they bind to extracellular matrix protein including laminin, fibronectin, and vitronectin. Prosthetic material implanted into humans become coated with these matrix proteins [11], thus explaining the ability of Brucella melitensis to infect devices and prostheses, even relatively long periods of time after insertion. Observations from several medical centers universally support complete removal of the device and the leads regardless of the extent of the infection to cure infection and reduce morbidity and mortality [12,13]. Complete removal of the prosthesis or the device followed by treatment with standard regimen for brucellosis results in good clinical outcome [14]. The recommended treatment of brucellosis is six weeks of oral doxycycline, combined with rifampicin for six weeks or parenteral streptomycin for two weeks [15].

Pacemaker pocket infection due to Brucella may be overlooked and misdiagnosed because of difficult diagnosis and the absence and lack of experience with laboratory testing. Alertness of medical staff is needed to recognize and diagnose the disease.

To the best of our knowledge, this is the first reported case of pacemaker pocket infection with Brucella meletensis in India.

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