Infective endocarditis in a haemodialysis patient: a challenging clinical case

Abstract

Introduction. Although haemodialysis is an irreplaceable treatment in the end-stage chronic kidney disease, it represents an important risk factor for haematogenous infections. Infective endocarditis is a rare and severe complication, accounting for 2 to 6% of haemodialysis patients. Case statement. We present a case of a 61 year-old female patient, admitted to the hospital with a 4-week vesperal fever up to 39ºC, anasarca and dyspnea. The list of previous comorbidities included: chronic glomerulonephritis from the age of 17, haemodialysis due to end-stage kidney disease (for the last 8 months), secondary arterial hypertension, secondary anemia, chronic viral hepatitis C and chronic atrial fibrillation. The presence of clinical data (decreased vesicular murmur on both lung bases, decreased sound I on apex and on tricuspid valve point, arrhythmic heart sounds, heart rate 110 bpm, blood pressure 125/45 mmHg) and laboratory systemic inflammatory response syndrome imposed the diagnostic work-up of an infection (pneumonia, urinary tract infections, endocarditis), malignancy, autoimmune disease. The chest X-ray showed the presence of Kerley lines, a small bilateral effusion and cardiomegaly. Repeated hemoculture, uroculture and oncological markers were negative and the pharyngeal swab revealed a high titer of Streptococcus viridans. The echocardiography performed on day 3 revealed: vegetation on the mitral valve (12x8mm) and on the aortic valve (9,6x7mm), dilation of all heart chambers; degree III-IV regurgitation on aortic, mitral and tricuspid valve, degree II-III regurgitation on pulmonary valve; ejection fraction of the left ventricle 52%, severe pulmonary hypertension. Under the treatment with vancomycin and gentamicin, the patient attended clinical stability and the decrease of vegetations’ size on repeated echocardiography. The patient underwent a successful cardiac surgery for mitral and aortic valve replacement. Discussions. In this multiple-problem patient, similar to other published studies, the valves affected by endocarditis were those aortic and mitral. A 2023 ESC Endocarditis Guidelines ”clinical stability” strategy was applied to this patient, resulting in a good surgical outcome, regardless of high preoperative risk. Conclusion. This clinical case demonstrates the difficulties in the diagnosis and treatment of endocarditis, in a multiple-problem haemodialysed patient. kidney disease, it represents an important risk factor for haematogenous infections. Infective endocarditis is a rare and severe complication, account ing for 2 to 6% of haemodialysis patients. Case statement. We present a case of a 61 year-old female patient, admitt ed to the hospital with a 4-week vesperal fever up to 39ºC, anasarca and dyspnea. Th e list of previous comorbidities included: chronic glomerulonephritis from the age of 17, hae modialysis due to end-stage kidney disease (for the last 8 months), secondary arterial hypertension, secondary anemia, chronic viral hepatitis C and chronic atrial fibrillation. The presenc e of clinical data (decreased vesicular murmur on both lung bases, decreased sound I on apex and on tricuspid valve point, arrhythmic heart sounds, heart rate 110 bpm, blood pressure 125/45 mmHg) and la boratory systemic inflammatory response syndrome imposed the diagnostic work- up of an infection (pneumonia, urinary tract infections, endocarditis), malignancy, autoi mmune disease. The chest X-ray showed the presence of Kerley lines, a small bilateral effusion a nd cardiomegaly. Repeated hemoculture, uroculture and oncological markers were negative and the ph aryngeal swab revealed a high titer of Streptococcus viridans. The echocardiography performed on day 3 revealed: vegetation on the mitral valve (12x8mm) and on the aortic valve (9,6x7mm), dila tion of all heart chambers; degree III-IV regurgitation on aortic, mitral and tricuspid valve, degree II-III regurgitation on pulmonary valve; ejection fraction of the left ventricle 52%, se vere pulmonary hypertension. Under the treatment with vancomycin and gentamicin, the patient atten ded clinical stability and the decrease of vegetations’ size on repeated echocardiography. The patient underwent a suc cessful cardiac surgery for mitral and aortic valve replacement. Discussions. In this multiple-problem patient, similar to other published studi es, the valves affected by endocarditis were those aortic and mitral. A 2023 ESC Endocarditis Guidelines ”clinical stability” strategy was applied to this patient, resulting in a good sur gical outcome, regardless of high preoperative risk. Conclusion. This clinical case demonstrates the difficulties in the diagnosis and treatment of endocarditis, in a multiple-problem haemodialysed patien t.