Fever, Myalgias, and Fatigue in a Woman Receiving Dialysis

For several days, a 60-year-old woman has had fever, myalgias, fatigue, poor appetite, and diminished oral intake. She denies cough, sputum production, and urinary symptoms.

HISTORY
The patient has a long history of hypertension, which resulted in end-stage renal failure that has required hemodialysis for the past year. Her long-term medications include lisinopril(Drug information on lisinopril), metoprolol, and amlodipine(Drug information on amlodipine). She has no history of paroxysmal nocturnal dyspnea, exertional dyspnea, or pedal edema. An echocardiogram obtained 1 year ago showed left ventricular hypertrophy and an ejection fraction of 65%. She denies alcohol(Drug information on alcohol) or illicit drug use.

PHYSICAL EXAMINATION
Temperature is 38.6^oC (101.7^oF); heart rate, 108 beats per minute; and blood pressure, 108/84 mm Hg. Head, ears, eyes, nose, and throat are normal, and lungs are clear. A grade 2/6 systolic murmur is evident but is difficult to characterize because of tachycardia. The right subclavian hemodialysis access site appears slightly red. Results of abdominal, neurologic, and extremity examinations are normal.

LABORATORY AND IMAGING RESULTS
Creatinine level is 10 mg/dL; blood urea(Drug information on urea) nitrogen, 41 mg/dL; potassium, 5.1 mEq/L; and sodium, 134 mEq/L. Anion gap is not elevated. Hemoglobin level is 8.7 g/dL, and white blood cell count is 11,900/μL. Chest film shows no infiltrates.

INITIAL HOSPITAL COURSE
Because of concern that the hemodialysis access site is infected, the patient is hospitalized. Blood samples for culture are obtained, and vancomycin(Drug information on vancomycin) is started at a renally adjusted dosage. The patient’s temperature decreases to 37.2^oC (99^oF), and she seems to improve. However, on her third day in the hospital, blood cultures from the first and second days show chains of gram-positive cocci. Vancomycin is continued, the hemodialysis line is removed, and an echocardiogram is ordered. That night the patient reports chest tightness and significant orthopnea. Her temperature remains 37.2^oC (99^oF), but blood pressure has fallen to 90/70 mm Hg. A third culture of previously drawn blood is positive for Enterococcus faecalis. An urgent echocardiogram reveals a left ventricular ejection fraction of 50% and vegetations on the aortic and mitral valves. The vegetations on the anterior leaflet of the mitral valve have resulted in severe mitral regurgitation directed posteriorly. Moderate aortic regurgitation is also evident. Gentamicin(Drug information on gentamicin) is added to the patient’s antibiotic regimen.

What is the most appropriate next step for this patient?
A. Repeat blood cultures and test for antibiotic resistance.
B. Add amphotericin to the antibiotic regimen.
C. Initiate medical therapy for congestive heart failure (CHF) and check for diuresis.
D. Obtain a cardiothoracic surgery evaluation for urgent valve replacement or repair.

(Answer and discussion on next page.)