Back pain and Staphylococcal bacteraemia in haemodialysed patients--beware!

was continued for 3 weeks and stopped only after Introduction blood cultures had become sterile. However, during this period the patient started to Staphylococcal infections are frequent in haemodiacomplain of severe, low, central back pain. On physical lysed patients, and Staphylococcus aureus bacteraemia examination no neurological deficit was elicited, but is associated with significant morbidity and mortality 45° hip flexion produced central back pain. Initial in these patients [1]. The most common port of entry lumbar vertebral X-rays were normal. Over the ensuing for Staphylococcal bacteraemia remains cannulation month the back pain continued unabated; the patient of the permanent dialysis access, or the use of centrallost 5 kg in weight and his serum albumin fell to vein catheters [2]. Haematogenous complications of 3.1 g/l. A technecium bone scan was negative. Staphylococcal bacteraemia include endocarditis, periIn late November 1995 the patient had further fevers carditis, pneumonia and empyema [3]. This article and MRSA was again isolated from blood cultures. describes two patients in which methicillin-resistant Despite removal of the indwelling catheter and reinstiS. aureus (MRSA) bacteraemia was complicated by tution of combined vancomycin and clindamycin metastatic foci of infection in both bone and the therapy the patient’s condition deteriorated. A CT nervous system. Both patients complained of severe scan of the lumbar spine disclosed complete destruction back pain, the importance of which will be discussed. of the body of 5 with a large paraspinal mass producing pressure on the dural sac. A diagnosis of pyogenic vertebral osteomyelitis, with spinal-cord comCases pression, was made. Surgical intervention was deemed necessary but the patient’s family refused. The family Patient 1 requested that the patient be discharged, and he died A 67-year-old man began chronic haemodialysis in shortly thereafter at home. Post-mortem was refused. July 1994 because of end-stage renal failure. In June 1995 his radiocephalic fistula thrombosed and a polytetrafluoroethylene graft was inserted into his right forePatient 2 arm. This graft thrombosed in October 1995 and an A 79-year-old woman with end-stage renal failure was attempt at thrombectomy was unsuccessful. A temporadmitted because of fever and a purulent exit site ary double-lumen haemodialysis catheter was inserted discharge from a temporary central-vein catheter. She into the left internal jugular vein. had been on maintenance haemodialysis for the precedFive days after insertion of the central-vein catheter ing 4 months. In 1981 she had undergone a total leftthe patient became acutely ill, with a high fever, chills knee replacement. Two weeks previous to the present and leucocytosis. The catheter was immediately admission the patient had a stenotic section of her removed and intravenous vancomycin and gentamycin radiocephalic fistula surgically corrected. Recovery had commenced. Subsequent blood and catheter tip culbeen uneventful and the patient was discharged with tures ‘grew’ methicillin-resistant Staphylococcus aureus the temporary central-vein catheter. (MRSA). Haemodialysis was maintained via temporOn initial examination the patient was alert, but ary femoral-vein catheters. Intravenous vancomycin febrile. Murmurs were heard over the cardiac apex and the right carotid artery. The catheter was removed, and intravenous cefazolin and gentamycin commenced. Correspondence and offprint requests to: Uzi Gafter MD, PhD, A transthoracic echocardiogram showed calcification Nephrology Department, Rabin Medical Center (Campus Golda), Petach Tikva, Israel. of the posterior mitral valve leaflet with mitral insuffi-