Chylous Collection in the Pacemaker Pocket Masquerading as Infection

BACKGROUND: Although a largely safe procedure, a variety of complications may arise from pacemaker implantation. One rare complication involves chylous collections forming at the pacemaker pocket. CASE SUMMARY: A 58-year-old woman with myotonic dystrophy and a dual-chamber pacemaker presented with chronic swelling over her pacemaker site. Imaging revealed a large fluid collection. Needle aspiration yielded 600 mL of milky, odorless fluid with a triglyceride level of 403 mg/dL, consistent with a chylous effusion. Lymphangiography and lymphoscintigraphy suggested impaired thoracic duct drainage, likely secondary to iatrogenic injury during pacemaker implantation. The patient was managed with a low-fat diet and remained asymptomatic without recurrence. DISCUSSION: Chylous fluid collections in pacemaker pockets are a rarely documented postsurgical complication. Understanding of diagnosis and treatment of this complication remains poorly explored. TAKE-HOME MESSAGE: This case emphasizes the need to consider lymphatic disruption in patients with persistent device site fluid collections.