Case Presentation: A 40-year-old male with a past medical history significant for right sided infective endocarditis and permanent pacemaker, status post removal due to infection, presented with complaints of fevers, chills, and hemoptysis for about two weeks. Hemoptysis was described as initially streaks in sputum to frank blood clots more recently. The patient denied any recent intravenous drug use, sick contacts, viral illness or chronic cough. Patient was recently incarcerated and currently homeless. Physical examination did not reveal any bleeding from mouth or nose. Chest x-ray was remarkable for a large cavitary lesion in the left lower lobe with air fluid level and foreign bodies coursing within. Computed tomography scan of his thorax reported a cavity 7cm x 4cm, mildly thickened walls, with fluid and air within, along with remnant cardiac leads. Patient was placed in isolation given risk factors. Acid-fast stain of sputum was negative on three appropriately timed samples. Cardiothoracic surgery was consulted and the patient was taken to the operating room for removal of foreign bodies. The surrounding lung, abscess and remnant leads were removed given the severity of adhesions and extent of abscess. Cultures were drawn and the patient was started on appropriate antibiotics.

Discussion: Cardiovascular implantable electronic devices (CIED) include pacemakers, implantable cardioverter defibrillators, and cardiac resynchronization therapy. These devices are being implanted more than ever due to the increasing age of our population and corresponding cardiac disease, along with expansion of indications. CIED related infections are outpacing the rate of increased implantation according to Medicare data. Removal of CIED following infection, device recall, upgrade, or other factors is not always possible leading to abandonment in the body.

This case demonstrated a rare but increasing complication associated with CIED. A recent review by Shaikhrezai, regarding retained epicardial lead complications, revealed 13 cases. The time from lead abandonment to complication ranged from as early as 12 weeks to as late as 24 years. While the majority of cases did survive, mortality was present in 1 case. Implantable devices are becoming more common place with advances in technology and expanded indications. These devices often fail, require upgrades, or may get infected in which case they may be abandoned in the body. Common implants range from CIED as in our patient, ocular lens, breast implants, defibrillators, as well as knee and hip implants.

Conclusions: Literature and cost analysis is sparse regarding complications related to implanted devices. As device implantation continues to increase in frequency, complications are likely to also increase. A device history should always be a part of a thorough history and physical examination.