Tricuspid Valve Endocarditis Beyond the Usual Suspects in a Hemodialysis Patient: A Case Report

Right-sided infective endocarditis (IE) is predominantly less prevalent than left-sided IE in hemodialysis (HD) patients because the left side is attributed to valvular damage from high-pressure circulation, endothelial vascular differences, and exposure to oxygenated blood. Right-sided IE is most commonly associated with intravenous drug use, central venous catheters, or intracardiac devices. However, it is associated with an increased mortality in HD patients. We present a case of an HD patient with no arteriovenous fistula (AVF) infection or history of intravenous drug use, who presented with right-sided IE. A 33-year-old man with a history of diabetes mellitus and end-stage renal disease on HD via an AVF presented with fever and chills after undergoing thrombectomy for right upper extremity brachial vein deep vein thrombosis, so he was discharged on two weeks of vancomycin administered with dialysis. The patient returned two weeks later for recurrent fever despite adherence to his antibiotic therapy. Blood cultures from previous and current admission grew methicillin-sensitive Staphylococcus aureus (MSSA), prompting echocardiography, which demonstrated tricuspid valve (TV) vegetation. The patient was transferred to a tertiary center and underwent endovascular mechanical aspiration of the TV vegetation by the cardiothoracic surgery team. His symptoms were resolved, and he was discharged on a six-week course of intravenous vancomycin 1 gram with hemodialysis and outpatient follow-up. Our case highlights a rare instance of TV vegetation in an HD patient with rapid onset of MSSA bacteremia following thrombectomy, despite the absence of AVF infection or other risk factors, suggesting hematogenous seeding during the procedure or AVF cannulation. We conclude that right-sided IE, particularly TV vegetation, should be considered in HD patients with persistent bacteremia, even in the absence of AVF infection or other identifiable causes of right-sided IE.