Pulmonary embolization with tunneled hemodialysis catheter-associated blood stream infection: the perils of systemic anticoagulation

A 35-year old African-American male with end-stage renal disease on hemodialysis through a tunneled dialysis catheter (TDC) presented with fever, diffuse aches and generalized distress. Blood cultures (BC) were obtained and empirical broad-spectrum antibiotic therapy started. After urgent renal dialysis, TDC was pulled at the bedside. Chest computed tomography (CT) diagnosed pulmonary embolism and systemic i.v. heparin was initiated. BC grew Gram positive cocci (methicillin-sensitive S. aureus) and cardiac echocardiogram confirmed acute bacterial endocarditis. Due to declined mental status, CT imaging was obtained revealing massive intracranial hemorrhage leading to the patient’s death. Further chest CT review revealed only hemodynamically non-significant pulmonary emboli in some segmental and subsegmental arteries. Pulmonary embolization may be an expected occurrence with removal of infected TDC; systemic anticoagulation may not be warranted in such cases and may lead to catastrophic intracranial hemorrhage. This case draws our attention to the perils of rigid adherence to protocol and the failure of considering the needs of special patient cohorts and individualized care.