A 53-year-old Egyptian female with end stage renal disease, one month after start of hemodialysis via an internal jugular catheter, presented with fever and shortness of breath. She developed desquamating vesiculobullous lesions, widespread on her body. She was in profound septic shock and broad spectrum antibiotics were started with appropriate fluid replenishment. An echocardiogram revealed bulky leaflets of the mitral valve with a highly mobile vegetation about 2.3 cm long attached to the anterior leaflet. CT scan of the chest, abdomen, and pelvis showed bilateral pleural effusions in the chest, with triangular opacities in the lungs suggestive of infarcts. There was splenomegaly with triangular hypodensities consistent with splenic infarcts. Blood cultures repeatedly grew
End stage renal disease (ESRD) is rampant in the population today. As per the data reported in the US renal data reporting system by the national institutes of health (NIH), the number of patients being treated by hemodialysis is at a record high [
Infective endocarditis is an infection of the endocardial layer of the heart. Patients receiving chronic hemodialysis are at an increased risk of infective endocarditis [
We report a case of severe endocarditis with marked complications associated with a temporary vascular access in a patient recently commenced on dialysis. We aim to shed light on the pitfalls of continuing dialysis on such forms of vascular accesses and to review the diagnosis and management of infective endocarditis in similar cases.
A 53-year-old Egyptian female with past medical history of hypertension with nephropathy leading to end stage renal disease, one month after the start of hemodialysis, presented with fever and shortness of breath at an Egyptian hospital. Blood cultures grew
On presentation at the referral center the patient was found to be in septic shock.
Her blood pressure on admission was 73/41 mm of mercury, with a heart rate of 120 beats per minute and a respiratory rate of 22 breaths per minute. Her white cell count on admission was 9,400 cells/
Image depicting severe end arteriolar embolic phenomenon to the nose.
Image depicting desquamating vesiculobullous lesions of the feet.
A transthoracic echocardiogram revealed bulky leaflets of the mitral valve with a highly mobile vegetation about 2.3 cm long attached to the anterior leaflet (Figure
Image depicting a transthoracic echo cardiogram, depicting vegetation and severe mitral regurgitation.
CT scan of the chest, depicting wedge shaped large pulmonary infarct.
CT scan of the abdomen, depicting splenic infarct.
Despite initiating parenteral antifungal therapy, the patient deteriorated over the course of 5 days. Her disease progressed to cause multiple organ failure and she was placed on palliative care due to grave prognosis and to honor the family’s wishes. She died due to a cardiac arrest.
The center for disease control and prevention (CDC) issued a dialysis surveillance report with data for participating centers the United States. This report utilized the CDC’s national health safety network (NHSN) for reporting facts about patients receiving hemodialysis. This network involved reporting of adverse events associated with dialysis and analyzing the data. Out of the 599 bacterial isolates from the 532 positive blood cultures following an adverse event, 77% (461 isolates) were associated with central lines. Although common skin contaminants took a major chunk of these isolates (44.3%),
It is interesting to note that fungal infections leading to endocarditis, similar to our patient, comprised of a mere 1.7% in Central line associated infections and 2.9% in fistula or graft associated infections.
Strom et al. reported a 16.9% relative risk of IE in hemodialysis patients in comparison to the general population [
Depicting vascular access infection rate by type of vascular access.
There is literature suggesting salvage of central lines if it is technically unfeasible to remove the lines. The suggested measures include antibiotic lock therapy with varying concentrations of solutions like antibiotics [
Some practices have been suggested to decrease the rate of infections associated with central lines; these include use of chlorhexidine impregnated dressings, catheter care with chlorhexidine solution, and dressing changes every 5–7 days. Catheter hubs and ports should be cleaned with either 70% alcohol or chlorhexidine [
Patients with ESRD have an increased incidence of heart valve disease. The valve disorders are secondary to calcification leading to regurgitation or stenosis [
ESRD results in an impaired immune status. This is multifactorial and includes a defect in antigen presenting cells. This leads to reduced stimulation of T Lymphocytes. This has been well documented and was originally observed due to decreased response to hepatitis vaccine in patients with ESRD [
Pathophysiology of impeded immune function in renal failure.
The diagnosis of infective endocarditis is specifically challenging in patients on HD. Duke’s criterion is most trusted for predicting and diagnosing infective endocarditis, but applying the criterion to patient with ESRD on HD is tricky. Duke’s criteria have major and minor criteria; one of the key major criteria is two positive blood cultures with an organism consistent with infective endocarditis, in the absence of a focus of infection. The frequent presence of a plausible source of infection, in the form of central lines, or ports can often make it difficult to differentiate between endocarditis and an uncomplicated line infection [
Thus echocardiography in the presence of a high suspicion of endocarditis in a patient with HD can be life-saving. Like any other patient with suspected infective endocarditis the initial imaging modality is a transthoracic echocardiogram, followed by a transesophageal echocardiogram if the image quality is questionable. Another indication of a transesophageal echocardiogram would be high suspicion even after a transthoracic study negates the diagnosis. Gaetano et al. published some high suspicion features mandating transesophageal study; these features are depicted in figure. They recommend a mandatory TEE with a TTE if any of these features are present (Table
High suspicion features mandating TTE in patients with HD and suspected IE.
High suspicion features for infective endocarditis mandating transesophageal echocardiogram after a TTE |
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(i) Patients with HD catheters |
(ii) New onset congestive heart failure |
(iii) Stigmata of endocarditis |
(iv) HD related hypotension in a previously hypertensive patient |
(v) Prior or repeated episodes of IE |
(vi) Prior valvular surgery |
(vii) Typical organisms for IE |
(viii) Relapsing bacteremia after antibiotic discontinuation, regardless of causative pathogen |
Gaetano et al., European heart journal (2007) 28, 2307–2312 doi:10.1093/eurheartj/ehm278.
The treatment of IE involves prompt diagnosis with the start of empiric therapy. After blood cultures have isolated an organism, a more directed approach can be followed. Table
Depicting the suggested treatment regime for infective endocarditis in the general population as per guidelines published in American Family Physician.
Treatment regimen for Infectious endocarditis in general population | |
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Empiric therapy | (i) Vancomycin or ampicillin/sulbactam with an aminoglycoside |
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Penicillin susceptible |
(i) Penicillin G or ceftriaxone for 4 weeks |
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Relatively penicillin resistant |
(i) Penicillin G or ceftriaxone for 4 weeks, plus gentamycin for 2 weeks |
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Penicillin-resistant |
(i) Ampicillin plus gentamycin for 4–6 weeks |
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Oxacillin- susceptible staphylococci | (i) Nafcillin or oxacillin for 6 weeks, plus gentamycin for 3–5 days (optional) |
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Oxacillin-resistant staphylococci | (i) Vancomycin for 6 weeks |
Special consideration should be made in patients with ESRD and vancomycin should be avoided for methicillin susceptible
Candida endocarditis is a rare entity in native valves, and the risk of having a fungal infection causing endocarditis rises in the immunocompromised, IV drug abusers, and in patients with indwelling foreign bodies like pacemakers, catheters, or prosthetic joints [
Operative intervention should be considered in all individuals with the criterion mentioned in Table
Indication of surgical management of Mitral valve IE.
Indications for surgery in native valve endocarditis of mitral valve |
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(i) Moderate to severe or severe mitral regurgitation with or without heart failure |
(ii) Vegetation size measuring more than 10 mm |
(iii) Mobile vegetation |
(iv) Paravalvular abscess |
(v) Evidence of a single embolic phenomenon including stroke |
(vi) Failure of antibiotic therapy |
(vii) Infection with a fungal organism |
[
Mitral valve insufficiency precedes the development of heart failure and early intervention is recommended to improve survival. Antibiotic therapy alone does not lead to an improvement of mitral insufficiency [
In case of a suspected embolic stroke, MRI scan of the brain is considered the most sensitive test for neurological imaging. Stroke can be seen in as much as 80% patients who have a left sided IE, on MRI scan. This MRI scan should be preceded by a noncontrast CT scan of the head to rule out bleeding; this may be secondary to a mycotic aneurysm and should warrant immediate neurosurgical evaluation. Patients with an active intracranial bleed are poor candidates for surgery [
Splenic infarction is frequent in left sided IE and should not delay surgery. A CT scan of the abdomen and pelvis should be performed to rule out a splenic abscess. The missed diagnosis of a splenic abscess has grave consequences as it may cause infections of the new valve [
Suggested preop workup for surgical candidates.
Suggested preoperative work-up prior to considering surgery | |
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(i) Embolic stroke |
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(i) More sensitive for neuroradiological diagnosis |
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(i) Pulmonary Infarcts |
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(i) More sensitive than TTE in visualization of vegetation |
[
The surgery should be timed as early as possible to avoid significant morbidity and improve survival. The main motive remains to avoid embolic phenomenon. There is limited data on the outcomes of valve surgery following infective endocarditis. A single center retrospective study noted that survival rates following surgery are acceptable with 30 day mortality at 8.5% and cumulative late mortality of 25.6% [
Advances in medicine, public health, and economic developments have added an extra decade of life to the average human lifespan. Hemodialysis vascular access for initiation of hemodialysis has become crucial. Catheters are still common form of vascular access used for dialysis initiation due to late placement of AVF before dialysis, primary AVF failure, urgent initiation following acute kidney injury, unexpected decline in glomerular filtration rate, medical insurance issues, Surgeon shortage, and a lack of predialysis nephrology care. All dialysis units should take a multidisciplinary approach and have a referral process early on for access creation and avoid catheters and associated mortality. Patients who are not candidates for fistulas and grafts, as well as peritoneal dialysis, should be involved in a detailed goal of care discussion. The aim should be improving maximal care while compromising least on the quality of life.
The authors declare that there are no conflicts of interest regarding the publication of this paper.
The authors acknowledge the sincere contribution of the Department of Nephrology and Internal Medicine.