Tricuspid Valve Infective Endocarditis in a Chronic Haemodialysis Patient with a Hickman Catheter: A Case Report

Infective endocarditis (IE) of the tricuspid and pulmonary valve accounts for 5 to 10% of all IE cases and, compared with left-sided IE, is often associated with intravenous (i.v.) drug use, presence of intracardiac devices, and central venous catheters (CVCs), including permanent-Hickman catheter (HC). We report a case of a 71-year-old female patient on a chronic hemodialysis (HD) program who had developed IE. Her first symptoms were fever and malaise. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) examinations were performed, revealing vegetations on the tip of HC and the anterior and posterior leaflets of the tricuspid valve (TV). Three blood culture bottles were positive for Enterococcus spp. The HC was replaced with a new CVC to continue HD. After a six-week antibiotic treatment, most clinical symptoms were resolved, and there was a decrease in vegetation size with normalization of inflammatory markers and negative follow-up blood cultures. After this initial improvement in the patient's condition, the clinical course was complicated by the development of Citrobacter koseri bacteremia and sepsis. Despite adequate antibiotic therapy, the condition progressed to septic shock, which was soon followed by a fatal outcome. IE treatment in HD patients requires long-term broad-spectrum antibiotic therapy, and also, in patients without arteriovenous fistula (AVF), the CVC should be replaced after each HD during IE and sepsis treatment to minimize the patient's exposure to a foreign body that is susceptible to bacterial colonization. A colonized foreign body is a focus for sustained and spreading infection, and its presence prevents adequate antibiotic treatment until the focus of infection is removed.