Endovascular fibrin sheath-associated methicillin-resistant Staphylococcus aureus bacteremia with Osler’s nodes

  • Aline Le
    Correspondence
    Corresponding author.
    Affiliations
    Virginia Commonwealth University School of Medicine, 1201 East Marshall Street #4-100, Richmond, VA 23298, United States
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  • Nasiffa Hossain
    Affiliations
    Virginia Commonwealth University School of Medicine, 1201 East Marshall Street #4-100, Richmond, VA 23298, United States

    Virginia Commonwealth University Health System, Department of Internal Medicine, 1101 East Marshall Street #1-030, Richmond, VA 23298, United States
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Open AccessPublished:April 14, 2021DOI:https://doi.org/10.1016/j.ijid.2021.04.042

      Case presentation

      The patient was a 31-year-old man with a history of uncontrolled type 1 diabetes mellitus and recent hospitalization for Fournier’s gangrene, requiring surgical debridement and antibiotic treatment via a central venous catheter. He presented to the emergency department with acutely worsening right shoulder and clavicle pain 4 days after a ground-level fall. The patient was ultimately found to be in septic shock due to persistent methicillin-resistant Staphylococcus aureus bacteremia.
      On presentation, the patient had a temperature of 36.7 °C (98.1 °F), blood pressure of 83/55 mmHg, heart rate of 127, and white blood cell count of 15.9. The patient appeared cachectic with an unremarkable cardiopulmonary exam. The scrotal surgical site appeared uninfected. Bilateral nodules were noted on his hands that the patient reported had been present for 2 weeks. We considered these likely to be Osler’s nodes (Figure 1).
      Figure 1
      Figure 1Nodules on dorsal surfaces of left hand.
      Computed tomography of the chest revealed pulmonary nodules concerning for septic pulmonary emboli (Figure 2). Following inconclusive transthoracic echocardiogram, transesophageal echocardiogram demonstrated mobile echodensity at the junction of the superior vena cava and right atrium, appearing similar to a central venous catheter. The finding was thought to likely represent an infected fibrin sheath of a central venous catheter removed 1 month prior (Figure 3, video) (
      • Hoshal Jr., V.L.
      • Ause R.G.
      • Hoskins P.A.
      Fibrin sleeve formation on indwelling subclavian central venous catheters.
      ,
      • Sheik M.A.
      • Shokr M.
      • Ibrahim W.
      • Cardozo S.
      Fibrin sheath-associated endovascular infection of the heart: the Trojan horse of indwelling central venous catheters.
      ).
      Figure 2
      Figure 2Computed tomography of the chest revealed multiple pulmonary nodules concerning for septic pulmonary emboli.
      Figure 3
      Figure 3Transesophageal  echocardiogram showing mobile echodensity at the junction of the superior vena cava and right atrium, likely to be an infected fibrin cast of a central venous catheter removed one month prior.
      The patient’s bacteremia cleared on day 9 of a 2-week course of vancomycin and was followed by an additional 6-week antibiotic treatment.

      Discussion

      Several studies have demonstrated the formation of a fibrin sheath around a central venous catheter which can develop within 24 h of placement and can persist after catheter removal. Fibrin sheath development serves as a potential nidus for catheter infection and other complications such as bacteremia and septic emboli as seen in this patient (
      • Hoshal Jr., V.L.
      • Ause R.G.
      • Hoskins P.A.
      Fibrin sleeve formation on indwelling subclavian central venous catheters.
      ,
      • Sheik M.A.
      • Shokr M.
      • Ibrahim W.
      • Cardozo S.
      Fibrin sheath-associated endovascular infection of the heart: the Trojan horse of indwelling central venous catheters.
      ).
      Given the increasing incidence of central venous catheter use, infection from a catheter-formed fibrin sheath should be readily considered as a source of infection in the setting of bacteremia and previous catheter placement (
      • Mehall J.R.
      • Saltzman D.A.
      • Jackson R.J.
      • Smith S.D.
      Fibrin sheath enhances central venous catheter infection.
      ,
      • Sheik M.A.
      • Shokr M.
      • Ibrahim W.
      • Cardozo S.
      Fibrin sheath-associated endovascular infection of the heart: the Trojan horse of indwelling central venous catheters.
      ). Transesophageal echocardiogram is imperative in evaluation of a fibrin sheath which often goes undetected in transthoracic echocardiogram (
      • Tang S.
      • Beigel R.
      • Arsanjani R.
      • Larson B.
      • Luthringer D.
      • Siegel R.
      Infective endovascular fibrin sheath vegetations — a new cause of bacteremia detected by transesophageal echocardiogram.
      ).

      Conflict of interest

      The authors have no conflicts of interest to declare.

      Funding source

      This report received no funding.

      Ethical approval

      All patient data were anonymized. The patient provided verbal consent for publication of the images and report.

      Appendix A. Supplementary data

      The following are Supplementary data to this article:
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