Dialysis catheter-related bacteremia, intractable abdominal angina and pyogenic vertebral osteomyelitis developed in a hemodialysis patient

Catheter-related bacteremia often causes serious complications in hemodialysis patients. We report a 72-year-old man on hemodialysis due to diabetic end-stage renal disease who developed catheter-related Stapylococcus aureus (S. aureus) bacteremia, intractable abdominal angina and pyogenic vertebral osteomyelitis. He was admitted to our hospital for progressive dyspnea and we started hemodialysis (HD) with an arteriovenous fistula in his left forearm. However, a dual-lumen catheter was placed in the right femoral vein because of arteriovenous fistula occlusion on the 14th hospital day. On the 35th hospital day, the patient developed a high fever with shaking chills. Because blood cultures from both the catheter lumen and a peripheral vein were positive for methicillin-resistant S. aureus (MRSA), the catheter was immediately removed and intravenous vancomycin administration was started at a dose of 500mg/day, twice weekly. However, treatment with systemic antibiotics alone failed to definitively eradicate the infection and the patient began to complain of intractable abdominal angina within two months. The cause of abdominal angina was unknown despite vigorous systemic examination, including contrast-enhanced magnetic resonance imaging (MRI). On the 120th hospital day, the patient developed severe back pain. On physical examination, there was no apparent neurological deficit, but T2-weighted MRI scan showed a high signal area and Gallium scintigram showed an abnormal accumulation of the isotope in Th12 and L1, suggesting vertebral osteomyelitis. Local drainage of the vertebral abscess as an adjunct to systemic antibiotic therapy was performed for eradication of the infection and amelioration of abdominal angina. We speculate that a disturbed microcirculation, associated with activated cytokine network by cell-surface-associated protein of S. aureus, such as intrleukin-1 and tumor necrosis factor, along with bacterial emboli might have played an important role in abdominal angina. This case has important implications for catheter-related S. aureus bacteremia in hemodialysis patients.