Case: A 58-year-old male with dual chamber pacemaker implanted 14 years previously for sinus node disease presented with red papular rash and burning pain over pacemaker site. He was initially treated with antibiotics for presumed device relate infection. Normal white cell count (WCC) and C-reactive protein (CRP), with negative blood cultures. Rash resolved during admission. The patient represented a few weeks later with similar clinical picture. A transoesophageal echocardiogram and PET CT scan showed no evidence of device infection. Given recurrent presentation, we proceeded to generator explant. No signs on infection on inspection of pocket and device.
Previous pacemaker checks had repeatedly shown low right-ventricular pacing percentages, in light of this, an implantable loop recorder (ILR) was inserted, which subsequently detected clinically significant sinus pauses. Patient incidentally also developed rash around the ILR site and was treated for presumed cellulitis.
A new left-sided pacemaker (St Jude Assurity) was implanted; within a month patient complained of a red vesiculopapular rash over pocket. When reviewed, there were no visible signs of rash or erythema. Patient remained systemically well, with normal inflammatory markers and negative blood cultures. We proceeded to complete system extraction. Lead tips were sent for microscopy and culture did not show any significant growth.
A new pacemaker (Biotronik) was implanted on the right side; within 2 weeks of implant, he represented similar symptoms. As previous, infection screen and repeat CT-PET did not show active infection.
Given the recurrent episodic nature of the flare-ups with significant impairment on quality of life, the right-sided device was extracted and a leadless pacemaker (MICRA) implanted. Symptoms completely resolved on the right side. Unfortunately, the patient sustained traumatic left rib fracture that required internal fixation with metal plates. Subsequently, a rash recurred over the left side of the chest.
The patient underwent a dermatology workup, an initial skin patch test performed and confirmed allergic contact dermatitis to nickel. Skin biopsy showed central areas of epidermal ulceration and inflammation. History, clinical picture, and histology would fit diagnosis of Grover disease.
Discussion: Grover disease, also known as transient acantholytic dermatosis, is characterised by erythematous popular/papulovesicular rash, typically on the trunk. The majority of patients are male, in their fifties and of Caucasian decent. The diagnosis is often clinical, supported by tissue biopsy. Common risk factors are malignancy, fever, sun exposure, hospitalization and being bedridden. It has not previously been described in association with pacemaker implantation.
Device-related rashes are rare and can be misdiagnosed as device-related infection. The relapsing-remitting nature of Grover disease makes diagnosis challenging, as often by the time patients are reviewed by clinicians, the rash has faded. Clinical history is important, lack of systemic symptoms, and absence of positive blood cultures, raised inflammatory markers, and additionally recurrence of symptoms on reimplantation at different site should raise suspicion of noninfective cause. ❑
