Implanting a gold-coated cardioverter-defibrillator as a solution to cardiac implantable device hypersensitivity: a case report.

Background: Hypersensitivity to cardiac implantable electronic device (CIED) materials is a rare and underrecognized complication. It often mimics infection, leading to misdiagnosis and inappropriate management. This case report contributes to the literature by demonstrating a structured diagnostic approach and the successful use of a custom-made, gold-coated ICD. Case summary: A 40-year-old male with dilated cardiomyopathy underwent subcutaneous ICD implantation. Seven months later, he presented with symptoms suggesting pocket infection, resulting in device removal. Subsequently, a transvenous ICD was implanted, but within weeks, signs of local inflammation reappeared, progressing to a necrotizing fistula. Blood tests and wound cultures revealed no infection. Given the patient's history of cutaneous allergic reactions to metals, hypersensitivity was suspected. Skin patch testing confirmed allergic responses to multiple device components. The patient underwent complete system extraction. A custom-made, gold-coated single-chamber ICD was provided by the manufacturer and successfully implanted. One-year follow-up revealed no signs of recurrent inflammation or allergic symptoms, confirming the diagnosis and effectiveness of the intervention. Discussion: Hypersensitivity to CIED materials is an important differential diagnosis in cases of recurrent pocket inflammation with negative microbiological findings. Due to overlapping local symptoms, it is frequently mistaken for infection, leading to delayed or inappropriate management. A detailed allergy history and use of skin patch testing are essential in guiding diagnosis. Once confirmed, conservative measures such as corticosteroids have limited value, and definitive treatment requires full system explantation. Reimplantation with a hypoallergenic device-such as a gold-coated generator-represents an effective therapeutic strategy.