Hemodialysis catheter infection with unusual presentation and grave outcome

Bacteremia from central venous catheter (CVC) infection causes morbidity and mortality in patients on hemodialysis (HD). Diagnosis of the infection can be difficult and may require special imaging. A 70-year-old man with diabetic nephropathy was on HD for 11 months through a permanent CVC. Because of symptomatic osteoporosis, he had kyphoplasty in three lumbar vertebrae (L2, L3, L4) 6 months after starting HD. Severe back pain persisted after kyphoplasty. Throughout the HD period, the exit site of the CVC had a clean appearance, there was no fever, and blood leukocyte counts were normal. During the 11th month of HD, he complained of subjective fever at home. Blood count revealed normal leukocyte count with neutrophilic predominance and blood cultures grew methicillin-resistant Staphylococcus aureus (MRSA). Echocardiogram revealed no heart valve vegetations, but irregular thickening of the CVC wall. Fluorodeoxyglucose positron-emission tomography-computed tomography (FDG-PET-CT) revealed severe inflammation of the CVC wall and a picture consistent with osteomyelitis and severe destruction of the body of the 11th thoracic vertebra. He was treated with intravenous vancomycin and removal of the CVC, the wall of which was grossly inflamed and grew in culture MRSA. Three weeks later, he discontinued HD because of persistent severe back pain. CVC infection with bacteremia and remote infectious foci having grave sequelae can develop in HD patients with paucity of clinical manifestations. FDG-PET-CT is a useful imaging tool in establishing the presence and extent of both the CVC infection and remote metastatic infectious foci.