A 72-year-old man received permanent pacemaker implantation (Medtronic, Minneapolis, MN) at our institution in 2010 due to sick sinus syndrome (Rubenstein III). No complications were seen during and post procedure. In April 2012 he experienced itching in his left anterior chest wall where the pacemaker was implanted. Soon, rash and heat sensation appeared at the same point. After 2 weeks, ulceration and exposure of the generator occurred. Ulcers were seen in 2 parts, the upper lateral area and the lower lateral area of the pocket, as shown in the Figure, panel A. Pocket infection was suspected, and generator removal was performed. However, infection control with antibiotics was not possible, and lead extraction was performed. After the lead extraction, another permanent pacemaker was implanted in the right anterior chest.

The risk factors for pacemaker infection have been reported, and they include diabetes mellitus, chronic kidney disease, thin subcutaneous tissue, age, and history of pacemaker infection.3 The only relevant risk in this patient was age, so it was reasonable to think about another factor involved in this pacemaker infection.

We assessed the possibility of contact dermatitis, but his patch test for each component of the Medtronic pacemaker was negative. From the appearance of ulceration, there were 2 ulcers in the same longitudinal line. Then we suspected that the cause of dermatitis was strap friction. The patient used to carry a backpack while walking 3 times a week and its weight was 2 kg (4.4 pounds) to 10 kg (22 pounds). The alignment corresponded perfectly with the backpack strap as shown in the Figure, panel C and D. Compression by backpack strap and their position in lateral line of the chest wall could provoke skin stretch and friction between the generator and the skin. Thereby, inflammation of subcutaneous tissue seemed to cause thinning of the skin and eventual exposure of the generator. This case reinforces that common activities of daily life have the potential to cause such complications, and the strap-induced dermatitis could have been avoided if we screened the risk of daily activities. We must know patient habits and their daily activities, and sometimes take their lifestyle modification into account to prevent adverse occurrences. The patient has remained free of complications since the second permanent pacemaker implantation 2 years ago.

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– Takumi Matsubara, MD, Takahiro Sato, MD, PhD, Satoshi Ohnishi, MD, PhD, Masao Yamasaki, MD, PhD

This article originally appeared in the September 2015  issue of The American Journal of Medicine.