Male, 65 years old, with chronic kidney disease on hemodialysis plan by native arteriovenous fistula in the left arm.
During the dialysis procedure, the patient developed general malaise and hypotension.
The patient was seen at the emergency room, where she was wet, febrile, polypnea, sinus tachycardia, blood pressure of 60/40mmHg, peripheral coldness, slow capillary refill.
Arteriovenous fistula without fimitus or beat.
Cardiovascular, respiratory and abdominal symptoms were normal.
Hemodynamic resuscitation measures were initiated in the emergency room, two blood cultures were extracted and admission to the intensive care unit (ICU) was requested.
The patient developed septic shock in the ICU. Empirical treatment with vancomycin and meropenem was started with a diagnosis of severe sepsis with no evident clinical focus.
Paraclinical tests showed the presence of severe metabolic acidosis with arterial lactate of 7meq/L, anemia with hemoglobin of 8.1g/dL and leukocytosis of 19000/mL.
Transesophageal echocardiography was requested, which ruled out the presence of endocarditis, and Doppler ultrasound of the left arm showed thrombosis of the arteriovenous fistula.
On the third day of evolution, a report is received from the hemocultives and culture of the dialysis water that develop R. pickettii.
Vancomycin was discontinued and meropenem was maintained for 14 days.
Good evolution with discharge from the ICU on day 6.
