PMC3738259_01
Erythematous rash on the abdomen and flank (case 1) primarily overlying the lead extensions.
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At one month post operation, the patient developed a left-sided rash on his flank and abdomen, with no fevers or chills (Figure 1).
Histopathology of soft tissue removed from the lead extension wound at the flank (case 1). Light microscopy revealed granulation tissue, necrotic debris, and fibrin with acute and chronic inflammation. No giant cell reaction was seen.
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A tissue biopsy was taken from the lead extension site (Figure 2).
The distal 4 cm of the lead extension pictured above was inserted via a 12 gauge angiocatheter into the subcutaneous tissue of the left buttock in case 1 for in vivo testing.
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In an attempt to rule out a hypersensitivity reaction, an in vivo allergy test using a portion of the extension lead was done (Figure 3).
PMC3738259_02
Persistent inflammatory reaction on the upper back (L2 level) 5 weeks post implantation in case 2. Lead strain relief is directly under the inflammatory tissue.
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However, despite resolution of the infection, the patient still had a skin inflammatory change that persisted for 5 weeks following implantation (Figure 4). The removal of the soft inflammatory tissue in Figure 4 revealed the underlying leads, and the pocket floor of the implantable pulse generator that had excess lead coils was notable for soft tissue inflammation.
(A) Histopathologic examination of skin and soft tissue specimen taken from the mid back (Figure 4), showing skin and subcutaneous tissue with ulceration and necrosis, acute and chronic inflammation, and a foreign body multinucleated giant cell reaction. (B) Arrow points to one of the many multinucleated giant cells seen close up from tissue detailed in (A).
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Intraoperative frozen sections revealed acute and chronic inflammation, with a foreign body giant cell reaction (Figure 5A and B).
PMC3738259_03
(A) Histopathology results for a specimen taken from the T2/3 level of the back (lead insertion wound). Microscopic analysis reveals granulation tissue with hemorrhage, acute and chronic inflammation, and a focal foreign body giant cell reaction. (B) Arrow points to multinucleated giant cell seen close up from tissue detailed in (A).
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Figure 6A and B displays the histology of the specimen results sent from the upper back wound.
Open wound of the right buttock with implantable pulse generator. The floor of the pocket has modest fibrous tissue with a collection of friable reactive tissue.
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An inflammatory reaction of the pocket floor was noted with very friable tissue (Figure 7).