The rate of implanted cardiac device infections ranges from 0.8 to 5.7 percent according to some reports. We report a very rare case of relapsing brucellosis due to intracardiac lead endocarditis and generator pocket infection at the same time.

A 56-years-old male patient who’d been implanted a pacemaker in 2003, presented to a state hospital in August, 2010 with complaints of night sweats and fever. In blood culture, Brucella melitensis was isolated. It was acquired from the consumption of unpasteurized cow milk. He was administered rifampicin and doxycycline for six weeks. But very soon his fever relapsed. He was diagnosed as B. melitensis relapse and treated by rifampicin and doxycycline for six weeks and streptomycin for 21 days, and his symptoms improved. Just after 20 days of the second therapy, his fever relapsed once more. This time brucella serology with standard tube agglutination (STA) was titer of 1:2560, and B. melitensis was isolated in blood culture again. Because of frequent relapses, the generator pocket was suspected to be responsible focus for relapses although there was no sign of inflammation in pacemaker pocket region. Patient then referred to our center but the patient has denied the therapy. After three years, patient has presented with fever again. B.melitensis was isolated from blood cultures of samples taken from the pacemaker pocket. Patient then referred to our center for further investigation. Transthoracic and transesophageal echocardiography showed no cardiac vegetation. The patient was pacemaker independent, so pacemaker generator and leads were removed and cultured. B.melitensis was isolated from cultures from the pacemaker pocket. Brucella was also cultured from the lead tips confirming the diagnosis of transvenous lead endocarditis. Antibiotic treatment consisted of 45 days regimen of 200 mg doxycycline and 900 mg rifampin and streptomycin 1g/day for 21 days, all administered orally. After completion of treatment, serologic tests and blood cultures were negative for brucella. To date there has been no recurrence of his illness.

The device and/or pocket itself might be the primary source of infection. Gram-negative organisms like brucella very rarely seed cardiac devices. In this case we presented here a device was infected secondarily but later behaved as a primary source of infection causing relapses of brucellosis. This case clearly demonstrates that if a patient with implanted cardiac device suffering from relapses of brucella despite effective antibiotic treatment, the infection of the implanted device by brucella should be kept in mind.