Miliary tuberculosis presenting as infection of a pacemaker pulse-generator pocket

A seventy year old woman had a permanent VVI pacemaker inserted in 1983 for complete heart block and presented ten years later with purulent discharge from the generator pocket. During a prolonged pyrexial illness, she developed renal and respiratory failure and her illness was complicated by recurrent ventricular fibrillation. The patient died on her 31st hospital day. Subsequent histological and microbiological investigation revealed widespread miliary tuberculosis which included involvement of myocardial tissue, great vessels and the pacemaker pocket. To our knowledge, this is the first reported occurrence of miliary tuberculosis involving a permanent pacemaker system. Furthermore, the granulomatous myocarditis which occurred as part of the miliary picture is a rare occurrence and possibly explains the recurrent ventricular fibrillation.