Male, 45 years old, personal history of smoker, hypertension, chronic kidney disease on hemodialysis plan due to prosthetic arteriovenous fistula in the right arm, renal failure with chronic rejection.
It begins 20 days before with a picture of upper respiratory infection receiving oral antibiotic treatment.
Continue episodes of fever and chills during dialysis procedures, entering the general ward, two hemocultives are extracted and treatment with ampicillin-disulfam is initiated with ceftazidime.
During evolution, the patient presented clinical bacteremia with hypotension, fever and pulmonary edema and was admitted to the ICU.
On admission, the patient was wet, febrile, hypotension of 90/60mmHg, well perfused, sinus tachycardia, polypnea, crackling rales at pleuropulmonary auscultation.
Fluid replacement, non-invasive mechanical ventilation, empirical antimicrobials and emergency hemodialysis were initiated.
Paraclinical evaluation showed leukocytosis of 15000/mL and anemia with hemoglobin of 8.9g/dL, type 1 respiratory failure with a PaO2/FiO2 index of 220.
A transthoracic echocardiogram was requested, which reported the presence of a vegetation of 2cm on the mitral valve; 24 hours later, a new transthoracic echocardiogram and a transesophageal echocardiogram were performed, which showed no vegetation.
Blood culture and dialysis water culture developed R. pickettii.
Antimicrobial treatment was adjusted to piperacillin-tazoate that was administered 21 days with good evolution being discharged from the ICU on the 12th day.
