A 46-year-old man with history of diabetes, hypertension, and renal failure presented with high fever, dyspnea on exertion, and pleuritic chest pain. He also complained of generalized lethargy and anorexia. Two weeks before admission, emergency hemodialysis had been initiated to manage worsening nephropathy; a dialysis catheter was placed in the right femoral vein.
The patient was listless, diaphoretic, and appeared to be using accessory muscles of respiration. Temperature was 39°C (102.2°F); pulse, 120 beats/min; and blood pressure, 106/50 mm Hg. Examination of the chest revealed decreased air entry at bases. Heart sounds were normal without murmurs. Findings from the abdominal and neurologic examinations were normal, and there was no evidence of leg swelling. Hemoglobin concentration was 14.4 g/L, and white blood cell count was 19.3 x 109/L (polymorphonuclear leukocytes 77%, band forms 16%, eosinophils 4%, and monocytes 3%). Figures 1 and 2 show computed tomography (CT) scans of the chest. Results of a lumbar puncture and a CT scan of the brain were unremarkable. Transesophageal echocardiography (TEE) found no cardiac vegetations. A culture taken from the catheter tip was positive for methicillin-sensitive Staphylococcus aureus.
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