Case Report: Catheter-Related Interatrial Septum Endocarditis Caused by Candida Parapsilosis

Keywords:
Renal Insufficiency, Chronic; Catheter-Related Infections; Endocarditis, Bacterial; Candida

Introduction

Patients with end-stage chronic kidney disease without mature arteriovenous fistula frequently require central venous access for dialytic therapy. More than 15 percent of patients who receive these catheters have complications such as infection, arterial puncture, thrombosis and pneumothorax.¹ Infective endocarditis (IE) is a rare and serious complication with high morbidity and mortality. Right-sided endocarditis is uncommon due to low hemodynamic pressure, but patients using central venous catheters have an increased risk.² The correct therapeutic approach whenever there is no valvar involvement is not well defined. We report a case of interatrial septum endocarditis caused by candida sp., associated to the prolonged use of catheter.

Case Report

A 49-year-old chronic dialysis female patient, with tunneled catheter due to multiple episodes of arteriovenous fistula malfunction, was sent from the dialysis clinic to emergency department. She had presented with fever and chills during dialysis sessions in the previous week. She also had dyspnea, dry cough and nausea.

At admission, she had a central venous catheter placed at the right subclavian vein with flogistic signs. Cardiovascular examination was normal, without murmur. There was no other relevant information in the physical examination.

Blood tests showed altered CBC (hemoglobin 9.6 mg/dL, leucocytes 3400 - 8.5% young forms) and positive inflammatory tests (C - reactive protein 26.2 mg/dL, reference level < 4 mg/dL). Cultures were positive for candida parapsilosis.

Chest X-ray showed no changes in lung parenchyma. A venous catheter was placed in the right atrium/inferior vena cava. There were no relevant alterations in the ECG. Transesophageal (TE) Echocardiogram (Figure 1) showed normal left and right ventricle and left atrium. The right atrium had a catheter inside, and a mobile image of 1.5 x 1.2 cm within the inferior vena cava, close to the catheter tip adhered to interatrial septum.

Figure 1
Transesophageal echocardiogram showing a mobile image (T) of 1.5 x 1.2 cm adhered to interatrial septum, close to the catheter (C) tip.

IVC: inferior vena cava; LA: left atrium; RA: right atrium; RV: right ventricle; LV: left ventricle; S: septum.

Since there was no valvar involvement, the heart team decided not to submit the patient to heart surgery. Antibiotic therapy was started with Amphotericin B and changed to Fluconazole after a fungal susceptibility test was performed. Control echocardiography after two weeks showed regression of the vegetation size. The patient was discharged with a prescription for oral Fluconazole 800 mg for dialysis days (three times a week). After three months, the patient was asymptomatic and control TE echocardiogram (Figure 2) did not show vegetation. Thus, antifungal treatment was suspended.

Figure 2
Control transesophageal echocardiogram performed three months after diagnosis showing complete regression of the thrombus.

S: septum; LA: left atrium; RA: right atrium; SVC: superior vena cava.

Discussion

IE is significantly more common in hemodialysis patients than in the general population.³ The use of a central venous catheter (either permanent or temporary) increases that risk.⁴

In patients on chronic HD, IE affects mainly native valves and only a small percentage of cases (20%) are seen in prosthetic valves.⁴ It usually involves the left side of the heart, but patients using central venous catheters have increased risk of developing right-sided IE due to mechanical injuries during guidewire insertion and forceful injection through the catheter.² Right-sided IE represents 5-10% of all IEs, and is classically related to intravenous drug use.⁵ IE affecting the interatrial septum is even less common and has only been described in association to prosthetic devices, such as valves and patches.⁶ As far as we know, this was the first case described of catheter-related interatrial endocarditis.

Common microorganisms causing IE in HD patients are staphylococcus aureus, enterococcus and streptococcus. Gram-negative species are rarely found, and fungal agents are even rarer.^5-7

Our patient had no heart murmur and no embolic or immunologic signs of endocarditis, making the diagnosis challenging. Especially in dialytic patients with long term venous catheters, the diagnosis of right sided endocarditis requires a high rate of suspicion. It is imperative that patients with long term catheters have the catheter's tip placed correctly in the superior vena cava, confirmed by imaging, in order to avoid complications.

There is no specific guideline recommendation for the treatment of IE without valvar involvement, so we chose not to operate on the patient even in the presence of fungal infection. We maintained antifungal therapy for approximately 4 months, and the drug was suspended after confirming complete regression of the lesion with TE echocardiogram. Removal of the permanent catheter in this situation is highly recommended.⁸

• Sources of Funding
  There were no external funding sources for this study.
• Study Association
  This study is not associated with any thesis or dissertation work.

References

• ¹
  McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2013;348(12):1123-33.
• ²
  Kale SB, Raghavan J. Tricuspid valve endocarditis following central venous cannulation: the increasing problem of catheter related infection. Indian J Anaesth. 2013;57(4):390-3.
• ³
  Abbott KC, Agodoa LY. Hospitalizations for bacterial endocarditis after initiation of chronic dialysis in the United States. Nephron. 2002;91(2):203-9.
• ⁴
  Kamalakannan D, Pai RM, Johnson LB, Gardin JM, Saravolatz LD. Epidemiology and clinical outcomes of infective endocarditis in hemodialysis patients. Ann Thorac Surg. 2007;83(6):2081-6.
• ⁵
  Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, Vilacosta I, et al; ESC Committee for Practice Guidelines. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Eur Heart J. 2009;30(19):2369-413.
• ⁶
  Osawa H, Saitoh T, Sugimoto S, Takagi N, Abe T. Dissection of intima on atrial septum patch after mitral valve replacement in a patient with infective endocarditis after incomplete atrio-ventricular septal defect repair: report of a case. Ann Thorac Cardiovasc Surg. 2004;10(2):124-5.
• ⁷
  Nori US, Manoharan A, Thornby JI, Yee J, Parasuraman R, Ramahathan V. Mortality risk factors in chronic hemodialysis patients with infective endocarditis. Nephrol Dial Transplant. 2006;21(8):2184-90.
• ⁸
  Bentata Y, Haddiya I, Ismailli N, Benzirare A, Elmahi O, Azzouzi A. Severe tricuspid valve endocarditis related to tunneled catheters in chronic hemodialysis patients: when should the catheter be removed? Arab J Nephrol Transplant. 2013;6(2):115-8.

Publication Dates

• Publication in this collection
  May-Jun 2017

History

• Received
  27 July 2016
• Reviewed
  03 Nov 2016
• Accepted
  23 Jan 2017