A Fatal Complication of A Peripheral Venous Catheter

doi:10.4236/ijcm.2012.35081

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International Journal of Clinical Medicine, 2012, 3, 433-437

http://dx.doi.org/10.4236/ijcm.2012.35081 Published Online September 2012 (http://www.SciRP.org/journal/ijcm) 1

A Fatal Complication of a Peripheral Venous Catheter*#

Lenneke E. M. Haas1, Bart C. Kortlandt1, Steven F. T. Thijsen2,3, Jan-Willem Fijen1,

Sanjay U. C. Sankatsing4

1Department of Intensive Care Medicine, Diakonessenhuis, Utrecht, The Netherlands; 2Department of Cardiothoracic Surgery, Uni-

versity Medical Center Utrecht, Utrecht, The Netherlands; 3Department of Microbiology, Diakonessenhuis, Utrecht, The Netherlands;

4Department of Internal Medicine, Diakonessenhuis, Utrecht, The Netherlands.

Email: [email protected], [email protected], sthijs[email protected], jwfijen@diakhuis.nl, [email protected]

Received May 31st, 2012; revised June 30th, 2012; accepted July 16th, 2012

ABSTRACT

Peripheral venous catheters (PVC) are widely used in the hospital and seem to be innocent. However, complication s can

be devastating. We present a case of a fatal septic shock due to vertebral osteomyelitis after PVC-rela ted St aph yloc occu s

aureus bacteremia (SAB). Staphylococcus aureus is a leading cause of bacteraemia in both the community and the hos-

pital with a significantly increased in cidence over the last several decades. Intravascular catheters are the most common

cause of SAB. Morbidity and mortality are high, even with appropriate therapy. Although complications are known and

common, they may be difficult to recog nize. Vertebral osteomyelitis is one of these known severe complications.

Keywords: Staphylococcus Aureus Bacteraemia; Vertebral Osteomyelitis; Peripheral Venous Catheter; Intensive Care

1. Introduction

Staphylococcus aureus is a leading cause of bacteraemia

and its incidence is still increasing. Predisposing factors

of S. aureus bacteraemia (SAB) are older age, intr avasc u-

lar catheters, wounds, needle use, co morbid illnesses

(diabetes mellitus, respiratory illness, malignancy) and

the use of immunosuppressive drugs [1,2]. Intravascular

catheters are the most common cause of SAB [3].

Complications of SAB are common, but may be diffi-

cult to recognize. Persistent fever and positive follow-up

blood cultures 48 to 96 hours after starting antibio tics are

predictive for subsequent complications [4]. Prior to the

discovery of antibiotics, SAB was fatal in more than 80%

of cases [5]. Nowadays, its mortality rate is still over

20% [6-8].

Hematogenous spread is the most frequent cause of

osteomyelitis and lumbar vertebral bodies are most often

involved [ 9]. Alth ough th e disc space has no d irect blood

supply, it can become secondary involved [10].

The incidence of vertebral osteomyelitis is about

1:350,000 and has steadily increased during recent years

probably as a consequence of the increasing rates of

nosocomial bacteraemia due to intravascular devices and

other forms of instrumentation, increasing age of the

population and more injection drug use [11]. The major-

ity of the patients are older than 50 years of age, whereas

men are affected approximately twice as often as women

[12]. Vertebral osteomyelitis (also named spinal osteo-

myelitis, spondylodiscitis, septic discitis, or disc space

infection) is a known severe complication of Staphylo-

coccus aureus (S. aureus) bacteraemia (SAB) which ac-

counts for more than 50 percent of cases. Other patho-

gens include Enteric Gram-negative bacilli, Pseudomo-

nas aerugino sa, Candida spp., Gr oups B and G hemolytic

streptococci and Mycobacterium tuberculosis [13].

Pain is the major sympto m, fever occurs inco nsistently.

The majority of patients have an elevated C-reactive

protein (CRP) and erythrocyte sedimentation rate (ESR),

leucocytes can be elevated or normal [14]. Blood cultures

are positive in up to 50 to 70 percent of patients [15].

Standard radiographic imaging often remain normal in

the early phases. Computed tomography (CT) can show

typical or suggestive changes in an earlier phase, al-

though subtle abnormalities may be missed. Magnetic

resonance imaging (MRI) is the most sensitive radiologic

technique for vertebral osteomyelitis although, 18F-fluo-

rodeoxyglucose-positron emission tomography (PET) is

a new promising tool [16]. The diagnosis can be con-

firmed by culture of the intervertebral discus or vertebral

bone tissue. However, when blood cultures from a pa-

tient with compatible clinical and radiographic findings

reveal a likely pathogen, a biopsy is not necessary [15].

Antibiotic therapy should be guided by culture results

including susceptibility testing. Parenteral antibiotics are

recommended [13]. The optimal duration of antibiotic

*None of the authors has a conflict of interest to declare.

#All authors contributed to the writing of this case report and they all

approved the final version.

A Fatal Complication of a Peripheral Venous Catheter

434

treatment is still not completely determined. Although

most patients respond to antimicrobial therapy, surgery

may be necessary in some patients.

We present a case of a fatal septic shock due to verte-

bral osteomyelitis after a peripheral venous catheter

(PVC)-related SAB. Although SAB is not uncommon,

we think this case is informative, because it illustrates

that a simple and widely used PVC can have devastating

complications, even when adequately treated.

2. Case Presentation

A 75-year-old woman was admitted to the orthopedic

ward because of severe back pain. Her medical history

revealed multiple osteoporotic vertebral fractures. CT-

imaging of the spine showed an osteoporotic fracture of

the 11th thoracic vertebral body (see Figure 1(a)), for

which she received oral analgesics and a back bracing.

Three days after admission, she collapsed and was trans-

ferred to our ICU. Clinical examination showed severe

hypotension and a newly developed partial paraplegia.

She was resuscitated with fluids and a vasopressor under

the suspicion of a neurogenic shock due to spinal com-

pression.

The initial laboratory results are shown in Table 1.

A MRI was performed, demonstrating a considerably

decreased and increased signal intensity of both the 10th

and 11th thoracic vertebral body and a partial compres-

sion of the myelum at this level on respectively T1 and

T2 weighted images (see Figures 1(b) and (c)).

Subsequently a laminectomy and spondylodesis was

performed to relieve the compressed spinal cord.

A review of the patient medical history revealed a

PVC-related SAB 3 months before which was treated

with intravenous flucloxacillin for two weeks. Because

of the suspicion of a pyogenic osteomyelitis, high dose

intravenous flucloxacillin (12 gram/day) was started.

Gentamicin was initially added, but was stopped after

two days. S. aureus was cultured from both blood and

from the vertebral disc and paravertebral fatbiopsies.

Since at this point an endo carditis was considered a tran-

sesophageal echocardiography (TEE) was performed

which showed no signs of endocarditis. Peroperatively

taken biopsies of the affected vertebral body showed

chronic inflammation.

Although initial hemodynamic improvement was seen

and signs of partial paraplegia decreased, her clinical

condition worsened in the follow ing days. She develop ed

multiple organ dysfunction syndrome (MODS) with he-

moynamic, respiratory, renal and intestinal failure and

disseminated intravascular coagulation (DIC). Because

of the progressive MODS and in view of her poor per-

formance state previously, it was decided to withdraw

life sustaining treatment. She deceased soon thereafter.

(a)

(b) (c)

(d)

Figure 1. (a) CT-image of the spine showing a new osteo-

porotic fracture of the 11th thoracic vertebral body with

bone fragments in the vertebral space and a paravertebral

hematoma; (b) T1-weighted MRI image, showing low signal

intensity at level Th10-Th11, suspected for fracture with

edema, metastasis or infection; (c) T2-weighted MRI image,

showing a considerably increased signal intensity of both

the 10th and 11th thoracic vertebral body and a partial

compression of the myelum at this level; (d) Autopsy pho-

tograph showing a part of the colon with greenish coating

and a large ulceration.

A Fatal Complication of a Peripheral Venous Catheter

435

Table 1. Laboratory results on admission to the ICU.

LABORATORY TEST VALUE REFERENCE VALUE

Leucocytes count 1.73 × 1010/L 4.0 - 10.0 ×109/L

C-reactive protein (CRP) 126 mg/L <10 mg/L

Sodium 131 mmol/L 135 - 145 mmol/L

Potassium 4.6 mmol/L 3.5 - 5.0 mmol/L

Urea 23 mmol/L 2.5 - 6.4 mmol/L

Creatinin 270 µmol/L 44 - 80 µmol/ L

Gamma- glutamyl transferase (GGT) 108 U/L <35 U/lL

Alkaline phosphatase (ALP) 256 U/L 35 - 120 U/L

Alanine aminotransferase (ALT) 57 U/L <45 U/L

Aspartate aminotransferase (AST) 130 U/L <40 U/L

Lactase dehydrogenase (LDH) 397 U/L <220 U/L

Amylase 616 U/L <100 U /L

Lactate 10.3 mmol/ L 0.5 - 2.2 mmol/L

Albumin 29 g/L 35 - 55 g/L

pH 7.18 7.35 - 7.45

pCO2 4.7 kPa 4.7 - 6.4 kPa

pO2 17.9 kPa 10.0 - 13.3 kPa

Bicarbonate 12.8 mmol/L 22 - 29 mmol/L

Autopsy was performed and revealed an ischemic l arge

intestine with ulcerations and vascular microthrombi (see

Figure 1(d)). Ischemia was thought to be due to the

combination of DIC with high dose nor adrenalin. Further

determination of the S. aureus was performed and it ap-

peared to be an enterotoxin B producing Panton Valen-

tine Leucocidin (PVL) negative strain which might at

least partially explain the pathologic findings of the large

intestine. During autopsy no signs of endocarditis were

found either.

3. Discussion

PVC-related SAB is still an under recognized complica-

tion. As presented in our case, this may have catastrophic

consequences, even when adequately treated.

What can we learn from this case? In retrospect, the

initial treatment might not have been adequate. Since a

purulent trombophelitis was present, a complicated SAB

should have been suspected and more than two weeks of

intravenous therapy should have been considered [17].

Unfortunately, no follow-up blood cultures after initia-

tion of treatment were taken and no TEE was performed.

If these cultures were taken and found po sitive, or in case

of development of complications, therapy indeed should

have been continued. Adherence to diagnostic and thera-

peutic guidelines of SAB still seems to be insufficient

[18]. It has been demonstrated that consultation of an

infectious disease specialist in case of a SAB results in

more frequent detection of endocarditis and metastatic

infection [19]. In our hospital we have a protocol in

which every patient with a SAB is consulted by a resi-

dent internal medicine under supervision of an infectious

disease specialist or microbiologist. Unfortunately, in

this case the protocol was not followed and there had

been no consultation.

In addition, there was a critical delay in diagnosis

since the complaints of ba ck pain were initially attrib uted

to the known degenerative spinal disease, whereas verte-

bral osteomyelitis was not considered despite multiple

positive blood cultures with S. aureus three months ear-

lier.

4. Conclusion

In this patient, a pyogenic vertebral osteomyelitis with

catastrophic consequences developed due to a PVC re-

lated SAB. This case illustrates that even a simple and

widely used item as a PVC can cause serious complica-

tions and that in case of a SAB consultation of an infec-

tious disease team might be beneficial. Furthermore, in

our opinion, all patients with a SAB, even when a com-

plicated infection is ruled out, should be instructed to

contact a physician in case of fever or other signs that

might suggest a metastatic infection.

5. Summary of Key Points

 Peripheral venous catheters (PVC) are widely used in

hospitals and seem very innocent. However complica-

tions can b e d evastati ng.

A Fatal Complication of a Peripheral Venous Catheter

436

 Staphylococcus aureus is leading cause of bacte-

raemia in both the community and the hospital and

the incidence is still increasing. Intravascular cathe-

ters are the most common cause of SAB.

 SAB has a high morbidity and mortality, even with

appropriate therapy. Endocarditis and vertebral osteo-

myelitis are two serious complication s of SAB.

 A minimum of two weeks of parenteral antibiotic

therapy should be given and follow-up blood cultures

should be ta ken.

 Consultation of an infectious disease specialist seems

of great additive value.

6. Acknowledgements

The authors would like to thank Dr. L. Wijnaendts, pa-

thologist and L. Sibinga Mulder, radiologist, both from

the Diakonessenhuis Utrecht, for their contribution to

this case report.

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Abbreviations

PVC: Peripheral venous catheter

SAB: Staphylococcus aureus bacteraemia

CRP: C-reactive protein

ESR: Erythrocyte sedimentation rate

CT: Computed tomography

MRI: Magnetic resonance imaging

PET: Positron emission tomography

TEE: Transesophageal echocardiography

MODS: Multiple organ dysfunction syndrome

DIC: Dissem inate di ntravascular coagul ati on

PVL: Panton Valentine Leuco cidin