Sepsis and Pulmonary Embolism Due to Catheter-related Right Heart Thrombus
We read with interest the article regarding right heart thrombus by Crowell et al (Chest 88; 94:1236-39). In the discussion, the presence of a central venous catheter is not mentioned as a cause of right heart thrombus, although in the literature the incidence is up to 29 percent. In the following case report, we would like to illustrate that a hemodialysis catheter can be the cause of right heart thrombus, intractable sepsis and pulmonary embolism.
A 68-year-old female dialysis patient was admitted to the hospital because of chronic low back pain. In 1983 hemodialysis was started because of end-stage renal disease due to diabetes mellitus and a left nephrectomy (infected nephrolithiasis). Diabetic macroangiop- athy resulted in amputation of the right leg in 1987.
Since November, 1987 hemodialysis was performed via a central venous catheter (polyurethane) because of vascular access problems. Every two weeks the catheter was changed over a guide wire. There were two documented (positive hemo- and catheter tip cultures) episodes of catheter sepsis: in April, 1988 with Strep fecalis and in May, 1988 with Staph epidermidis.
A spondylodiscitis was thought to be the cause of the low back pain since a vertebral hot spot was detected on bone scintigraphy and confirmed by CT scan. Three days after performing a biopsy of the suspected vertebra the patient developed fever. All hemocul- tures were positive for Staph epidermidis. The same organism was found on the tip of the catheter and in the biopsy specimen of the vertebra. Echocardiography was negative. In spite of adequate antibiotic therapy with vancomycine and tobramycine and removal of the catheter her condition deteriorated quickly and she died 24 days later of septic shock. Autopsy revealed a right atrial thrombus and multiple pulmonary emboli. Cram stain and culture of the tissue was positive for Staph epidermidis.
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We suppose that the atrial thrombus was induced by the permanent (12 months) presence of a central vein hemodialysis catheter. Several periods of catheter sepsis resulted in spondylodiscitis and colonisation of the thrombus, finally causing intractable septic shock and pulmonary emboli. Long-term central venous cannulation increases the risk of right heart thrombi. Therefore, we suggest that central venous catheters must be included in the list of causes of right heart thrombi.