PS-R05-5: A CASE OF SEPTIC PULMONARY EMBOLISM DUE TO MITRAL VALVE ENDOCARDITIS OCCURRING EARLY IN THE INDUCTION PHASE OF HEMODIALYSIS

Abstract

A 66-year-old man with end-stage kidney disease (ESKD) due to chronic glomerulonephritis who was scheduled to start hemodialysis after surgery for radiocephalic arteriovenous fistula (AVF) was admitted to our hospital because of volume overload. He developed fever and cough after an upper endoscopy was performed on the 20th hospital day. Chest CT revealed an infiltrative shadow in the right lower lung and he was diagnosed with bacterial pneumonia and treated with sulbactam/ampicillin and azithromycin. Two sets of blood cultures were negative. There were no findings suggesting infection of the AVF. His fever persisted and repeated CT on day 37 showed multiple nodule shadows along the blood vessels in the left lower lobe. We suspected septic pulmonary embolism (SPE) and transthoracic/esophageal echocardiography showed a newly developed MV regurgitation (MVR (II/IV), with a 17 mm vegetation and partial perforation. Repeat physical examination revealed nontender, small erythematous (Janeway) lesions on the toes and a new holosystolic murmur at the apex (II/VI). (The patient said he had similar lesions on his hands but they had disappeared.) Due to the accumulation of Ga-67 citrate in the peri-oral area and the MV, caries and periodontal disease were thought to be the source of infection. Infectious endocarditis (IE) was diagnosed based on modified Duke criteria. Ceftriaxone was added to cover gram-negative bacilli in the oral cavity, including HACEK (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella). Antibacterial treatment reduced the size of the vegetation and the MVR improved. Pulmonary nodules also disappeared. Dental treatment was performed after the vegetation had almost disappeared. Three additional sets of blood cultures were also negative. There have been few reports of SPE due to left sided IE. The onset of SPE in this case may have been caused by an embolus that formed in the MV and flowed into the right sided heart via an AVF, as emboli were also found in the peripheral extremities.