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An Antisepsis Misfortune: Povidone-Iodine-Induced Chemical Burn Near the Pacemaker Implantation Site
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J INVASIVE CARDIOL 2024. doi:10.25270/jic/24.00261. Epub September 12, 2024.
A 76-year-old woman was scheduled for pacemaker implantation due to sick sinus syndrome. The skin was prepared with the usual povidone-iodine solution. During the procedure, she experienced intense burning and discomfort on the left upper chest and left armpit, though no skin wound was initially observed. The implantation was completed successfully, but the following day she demonstrated fatigue, fever (38.7 °C), elevated C-reactive protein values, and a painful, erythematous axilla with large areas of epidermal blistering, exfoliation, and weeping wounds (Figure A, asterisk) suggesting a severe chemical burn. Interestingly, the presence of Nikolsky’s sign, indicated by the dislodgment of the epidermis with lateral pressure at non-blistered wound areas, raised concerns of serious skin infection.
Our case presented an alarming situation for the following reasons: the axilla is rich in microflora, including staphylococci and yeasts; the proximity of the burn to the pacemaker implantation site; and the lack of clear guidelines for managing infections near cardiac devices.
The patient was closely monitored and treated with empirical intravenous antistaphylococcal and antifungal therapy (vancomycin and fluconazole). Wound care involved gentle cleansing, non-dressing at all, and L-Mesitran ointment, a medical-grade honey-based product with antimicrobial, anti-inflammatory, and wound-healing properties. The patient’s general condition and laboratory indices of inflammation rapidly improved. Over the next few days, the wound stabilized and the necrotic tissue sloughed off, revealing granulation tissue beneath (Figure B and C), while Nikolsky’s sign was no longer present. No centrifugal expansion towards the implantation site was noted (Figure D). Wound cultures isolated staphylococcus epidermidis and antibiotics were deescalated accordingly. The patient was discharged on postoperative day 7 with oral antibiotics and wound care instruction. Skin re-epithelialization was gradually observed, and no signs of long-term scarring or functional impairment were present on follow-up visits at 3 (Figure E) and 4 weeks (Figure F) post-implantation.
Chemical burns are typically considered a rare complication of povidone-iodine use, often with a benign clinical course. They can arise when the solution is not allowed to dry completely, pools in dependent areas, or is covered by an occlusive dressing. Irritation from iodine, combined with maceration, pressure, and friction, may contribute to the development of such burns. Our rare case highlights the potential complications of povidone-iodine use, especially in microbiota-rich areas. The risk of infection is significant, particularly near implanted medical devices, and current literature lacks clear guidelines for such situations.
Our approach provides a potential treatment pathway and underscores the need for close monitoring and infection prevention. Further research is necessary to establish standardized management protocols for these challenging cases.
Affiliations and Disclosures
Dimitrios Karelas, MD, MSc1; Nikolaos Platogiannis, MD, MSc2; George J. Papanikolaou, MD3; John Papanikolaou, MD, PhD2
From the 1Cardiology Department, Hellenic Red Cross Hospital Korgialenio-Benakio, Athens, Greece; 2Cardiology Department, Trikala Hospital, Trikala, Greece; 3School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.
Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.
Consent statement: The authors confirm that informed consent was obtained from the patient for the study and intervention described in the manuscript and to the publication of their data.
Address for correspondence: Dimitrios Karelas MD, MSc, Athanasaki 2, Athens 11526, Greece. Email: dim.f.karelas@gmail.com
