**8.2 Diagnostic challenges**

 Beyond the typical and distinct clinical manifestations, there are also many cases with scarce or misleading symptoms. One study reports that many diagnostic delays are related to the fact that CIED infection was not considered in the original differential diagnosis, for instance, when device patients present with mainly respiratory or rheumatic symptoms that are interpreted as bronchitis [5, 47]. Other reasons for delay could be that possible hints about the diagnosis were disregarded, for instance positive blood cultures for *Staphylococcus epidermidis* first considered to represent contamination. Sometimes, the diagnosis was taken into consideration, but wrongly excluded without adequate investigations, such as a negative transthoracic echocardiography (TTE) being interpreted as sufficient for excluding the diagnosis [47].
