The patient is a 53 years old female with the
history of systemic arterial hypertension with 3 years of diagnosis, in
treatment with ARB losartan 50 mg PO BID. End Stage Chronic Kidney Disease with
3 years of diagnosis, with no determined cause, with instalation of IJ central
venous catheter on 13 June of 2016 and starting hemodialysis, 3 sessions per
week. No other history of importance.
Initiating with malaise, fatigue, dyspnea and
cough with sputum, 48 hours later after a hemodialysis session, initiating with
unquantified fever on 07/20/2016. She is then hospitalized for in depth
examination.
During hospitalization, it is registered low blood
oxygen saturation being as low as 61%, a chest X-Ray is taken with an image
compatible with a right basal consolidation. Relevant in Physical exploration
is in posterior Thorax presence of crackles on the right inferior area. On the
Anterior Thorax presence of a heart murmur III/VI on the tricuspid. Treatment
with moxifloxacin is initiated. Routine blood tests are taken with results in
results:
07/25/16: glucose 166 urea 128.9 creatinine 6.8
uric acid 9.1 albumin 1.87 Na 125.1 K 4.4 Ca 7.6 F 3.5 leukocites 32.12
neutrophils 26.6 Hb 6 VCM 89.5 MCHB 28.64 Platelets 167.5 procalcitonin >200.
Kidney USG: diffuse chronic changes associated
with acute inflammatory process and increased diameter of urether on the left
kidney.
Blood Cultures are taken with growth of Staph.
Aureus methicillin sensible. The IJC was removed another was placed at femoral
vein and continuing hemodialysis.
Ecocardiogram: left ventricle with 76% EF with
alterations in diastole, aortic and mitral valves normal, adhered mass on the
lateral part of the tricuspid ring and/or valve approximately 22x6 mm
suggestive of vegetation. PSAP 42 mmHg (unfortunately no images were available).
Diagnosing infective endocarditis and septic pulmonary embolism.
After an infectology consult, antibiotic
treatment was changed to imipenem/cefalotin. Also a consult for thoracic
surgery was made whom suggested a valve exchange due to the size of vegetation.
There was no requirement of vasopressors.
Finally the patient was moved to the coronary
unit and valve was exchanged. By the time patient has ben continuing
hemodialysing throught femoral catheter.
Pending the images
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