Authors: Ziad Affas, Anuradha Sreenivasan, Vijay Patel.
Patients with end-stage renal disease (ESRD) will likely need vascular access for hemodialysis, the vascular access increases the risk of having bloodstream infections such as Catheter-Related Bloodstream Infections (CRBSI). Rarely some patients may have non-valvular endocarditis. Fibrin sheath usually plays a role in this infection, and these can be identified on a transesophageal echocardiogram (TEE). ESRD patients can present without fever in cases of endocarditis due to uremia impaired cellular host defenses, therefore, a low threshold for TEE should be considered in these patients. We report a case of SVC endovascular endocarditis in the setting of MSSA bacteremia in an ESRD patient.
A 49 -year-old female with a past medical history significant for ESRD secondary to diabetic nephropathy on dialysis with a tunneled subclavian hemodialysis dialysis catheter. Presented to the hospital for a chief complaint of fever for 2 days duration. The patient was vitally stable on admission; the area around the catheter was indurated and tender. The patient had a blood culture on the first day of her fever, it came back positive upon admission as the blood culture showed staphylococcus aureus bacteremia, and the patient was started on IV Vancomycin.
Ultrasound was done and showed an abscess surrounding the dialysis port. TTE was done and showed no obvious evidence of endocarditis. TEE was done which demonstrated a large, mobile RA mass consistent with vegetation, which is attached at the lower junction of SVC and right interatrial septum. Angiovac of vegetation was done. The catheter was out. Blood culture sensitivity grew MSSA, susceptible to ancef, therefore vancomycin was switched to ancef 2g for a total of 6 weeks.
Clinical suspicion should always be high for endocarditis in patients with fever and having dialysis catheter. TTE can be negative many times in these patients; therefore, having a high index of suspicion should always be there in these patients. Non-valvular endocarditis such as superior vena cava endocarditis is very uncommon and is only documented in a few cases in the literature. This infection responds very well to the antibiotic and Angiovac is helpful in these situations too.
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