While pacemaker implantations are generally safe, they can pose unique challenges, especially in patients with complex medical histories. A recent case study, drawing attention for its rarity and multidisciplinary significance, highlights the unusual interplay between cardiac procedures and inflammatory disorders. The case, involving a patient with gouty arthritis, brings to light an extraordinary complication following pacemaker implantation. This scenario, though rare, underscores the potential for unexpected outcomes in high-risk patients, particularly those with conditions like coagulopathy and heart failure, and the need for greater understanding of the link between inflammatory disorders and pacemaker complications​​.

In the realm of medical oddities, a recent case has emerged that intertwines cardiology and rheumatology in an unexpected way. Dr. Surachat Jaroonpipatkul, Dr. Thipsukhon Sathapanasiri, Dr. Sungchai Aungthararak, Dr. Apichai Pokawattana from Rangsit University, and Dr. Leenhapong Navaravong from the University of Utah Health, encountered a unique case of gout manifesting in a pacemaker pocket, as reported in Heart Rhythm Case Reports. This case highlights the complexities and multidisciplinary nature of certain medical conditions.

The patient, a 64-year-old Thai man, presented a perplexing medical scenario. He had a history of various chronic conditions, including gouty arthritis, and underwent a pacemaker implantation in April 2020. Two years later, he exhibited symptoms of pacemaker-induced cardiomyopathy and was scheduled for a cardiac resynchronization therapy upgrade. However, the procedure was unsuccessful due to anatomical limitations.

One month following the failed upgrade, the patient returned with swelling at the pacemaker wound site, but without fever or pain. Examination revealed a painless swelling at the site and gouty tophi on his lower extremities. Investigations including an ultrasound and chest radiograph revealed a fluid collection in the pacemaker pocket. Despite antibiotic treatment, the swelling persisted, leading to a decision for wound revision surgery.

The surgery uncovered bloody content with chalk-like material in the pacemaker pocket, which was later analyzed and found to contain clotted blood and uric acid crystals, confirming the diagnosis of a gout-related complication. Dr. Jaroonpipatkul explained, “In our patient, elevated serum uric acid levels, bilateral tophi on the lower extremities, and bloody fluid with chalk-like content along with monosodium urate crystals pointed to the diagnosis of pacemaker pocket hematoma with cystic gout. The abnormal location of MSU crystal formation in the pacemaker pocket is a unique aspect of this case.”​​

The patient’s condition improved following intensive serum uric acid control and wound care, highlighting an unusual case where gout manifested in an extra-articular location—specifically, within the space created for the pacemaker rather than the typical joints. Dr. Jaroonpipatkul noted, “Discovering a surprising link between gout and cardiac devices, this study goes ‘Beyond Arthritis.’ It encourages all doctors to work together, looking at the bigger picture of patient care. By combining efforts, we can prevent potential health issues and provide better overall support. This research connects cardiology and rheumatology, highlighting the importance of teamwork for patient well-being.” 

This case underscores the importance of considering comorbidities in patient care, especially in those with complex medical histories. It also highlights the need for holistic and multidisciplinary approaches in medical practice. The interplay between the patient’s gout and his cardiac condition posed unique challenges and required the expertise of both cardiologists and rheumatologists to manage effectively.

In conclusion, this extraordinary case adds to the medical literature by illustrating a rare manifestation of gout and the need for vigilance in the care of patients with multifaceted medical conditions.

Journal Reference:

Jaroonpipatkul S., Sathapanasiri T., Aungthararak S., Pokawattana A., Navaravong L. 2023. Extra-articular bloody tophi in pacemaker pocket: A case report. Heart Rhythm Case Reports. DOI: https://doi.org/10.1016/j.hrcr.2023.07.008.

About the Author

 Dr. Surachat Jaroonpipatkul, a renowned cardiologist based in Bangkok, Thailand, earned his Doctor of Medicine from Rangsit University. As a Lecturer and Consultant in Cardiology at Rajavithi Hospital and Rangsit University, he specializes in clinical cardiology, focusing on pacemakers, defibrillators, and cardiac electrophysiology. Driven by a passion for medical education, he guides and mentors students, residents, and fellows, contributing significantly to their academic growth. His dedication extends to administrative roles at Rajavithi Hospital. With a strong research background, Dr. Jaroonpipatkul has authored publications on diverse cardiology topics. Committed to global knowledge sharing, he actively participates in workshops and lectures, embodying excellence in both cardiology practice and medical education.