A Rapidly Deteriorating Case of Bivalvular Endocarditis in a Hemodialysis Patient: A Case Report

Infective endocarditis (IE) is a rare but potentially life-threatening condition characterized by inflammation and infection of the inner lining of the cardiac chambers, native or prosthetic valves, or indwelling cardiac devices. In recent decades, its incidence has increased exponentially in healthcare-associated settings such as hemodialysis (HD). The primary causative agent is typically <i>Staphylococcus aureus</i>, followed by streptococci and, in some instances, even fungal infections, although infectious agents do not exclusively cause the condition. In this case report, we detail the clinical presentation of a 46-year-old morbidly obese male with a medical history notable for hypertension, poorly controlled diabetes, and end-stage renal disease necessitating HD. Upon arrival at the emergency department, he presented following a two-week lapse in dialysis sessions, reporting symptoms of altered mental status and lethargy. Shortly after that, the patient's condition rapidly deteriorated, marked by fever, vomiting, and indications of septic shock. Physical examination revealed signs consistent with meningism, alongside the identification of a clotted radio-cephalic fistula, impeding vascular access essential for HD. Furthermore, severe uremia was evident, attributed to the prolonged absence of dialysis treatment. Concurrently, given the patient's presentation of meningeal signs, we were concerned about a potential diagnosis of meningitis. Our immediate priority was to stabilize the patient's vital signs and address the resolution of potential uremic encephalopathy. Additionally, we prioritized the investigation of possible sources of bacterial infection that could be contributing to septic shock and sudden deterioration. This case highlights the complex presentation of IE, which necessitated the collaboration of multidisciplinary teams to address the patient's condition. Additionally, emphasis is placed on HD as a major risk factor for IE, with discussion of associated factors such as constant manipulation of skin flora during dialysis, types of vascular access utilized, and the potential for fistula infection to directly or indirectly contribute to IE. Furthermore, we explore the idea of a possible link between meningism or meningitis and IE.