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A 41-year-old male on hemodialysis via a tunneled cuffed hemodialysis catheter (TCC) due to hypertensive chronic kidney disease since 2 years prior, was referred because of decreased vision and fever. He had never undergone AVF or arteriovenous graft surgery, because he was preparing for a living donor kidney transplantation from his sister, but the transplantation was delayed because of his obesity (body mass index, 31.2 kg/m2). Three days before admission, he complained of pain and swelling at the TCC insertion site and was treated with oral antibiotics and antipyretics. On physical examination, the skin around the exit site of the TCC showed redness, a warmness to the touch and tenderness (Fig. 1A). The left eye showed conjunctival infection. A slit lamp examination showed grade II anterior chamber cells and an exudate membrane in the left eye (Fig. 1B). In fundus photography, vitreous media was opaque in the left eye (Fig. 1C, D). His right eye best-corrected visual acuity (BCNA) was 0.8 (20/25), and his left eye BCNA was 0.08 (20/250). A diagnosis of endogenous endophthalmitis was made. To find the sources of endophthalmitis, abdominal-pelvic computed tomography and transesophageal echocardiography were performed and showed nonspecific findings.
The TCC was removed immediately. He was treated with systemic antibiotics (vancomycin and moxifloxacin) and intravitreal antibiotics (vancomycin and ceftazidime). On the 5th day after admission, methicillin-resistant Staphylococcus aureus was grown in the only culture of the TCC tip, therefore, a diagnosis of endogenous bacterial endophthalmitis (EBE) from the TCC was confirmed. On day 11 after admission, he complained of pain in the left eye, and the slit lamp examination showed aggravated findings in vitreous and fundus appeared opaque (Fig. 1E). On the 12th day after admission, pars plana vitrectomy (PPV) was performed. On 26thday after admission, his left eye BCNA was 0.1 (20/200) and he was discharged with a prescription for oral antibiotics.
Endogenous endophthalmitis is very rare in hemodialysis patients without diabetes mellitus or immunosuppressive disease.1 Past studies have reported seven cases associated with the use of a TCC12345 and there were some common features that differed from our case. First, the patients had additional risk factors for EBE, such as diabetes or Wegener's granulomatosis with immunosuppressant therapy. Second, the patients were relatively old (mean age: 58.8 years). In our case, the patient was younger and did not have diabetes mellitus or other immunosuppressant disorders. However, he was using the TCC for long periods compared with previous cases. As described in our case, clinicians should be advised that the long-term use of a TCC (more than 2 years) can result in EBE in young hemodialysis patients who do not have diabetes or other immunosuppressive disorders.
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