Cutaneous warning signs of cardiac implantable electronic device infection: a pictorial guide for clinicians

Cardiac implantable electronic device (CIED) infections are potentially life-threatening complications of pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy devices. Although fever, bacteremia, and infective endocarditis may occur, the earliest—and sometimes only—manifestations are cutaneous abnormalities overlying the generator pocket. These findings may be subtle and mistaken for postoperative changes, hematoma, contact dermatitis, mechanical irritation, or impaired wound healing. Because patients may initially present to general practitioners, internists, emergency physicians, or dermatologists, early recognition is essential. This pictorial review illustrates the spectrum of cutaneous manifestations of CIED infection, ranging from localized erythema, swelling, pain, and delayed wound healing to erosion, sinus tract formation, purulent drainage, necrosis, and hardware exposure. It also highlights practical warning signs, appropriate referral pathways, and interventions that should be avoided before specialist assessment. Infection may extend from the pocket along the intravascular leads to the bloodstream and cardiac structures, leading to bacteremia, endocarditis, sepsis, and death. Any persistent or progressive abnormality over a CIED pocket warrants prompt evaluation, whereas purulent drainage, sinus formation, or hardware exposure should be considered evidence of device infection and require urgent electrophysiology assessment, even in the absence of systemic symptoms.