STAPHYLOCOCCAL BACTEREMIA

Clarence Peters, a pseudonymous 45-year-old African-American man with end-stage renal disease (ESRD) secondary to chronic glomerulonephritis presented for a regular hemodialysis treatment with pain in the right upper arm. He had been on chronic in-center hemodialysis for 20 months. During that time he had undergone numerous surgical interventions for insertion and/or thrombectomy of polytetrafluorethylene (PTFE) grafts for vascular access, including a chest wall subclavian artery-to-subclavian vein graft. The most recent procedure, about two months earlier, had placed a graft in the medial area of the right upper arm, from axillary artery to cephalic vein. He now complained of sharp pain of acute onset and about one-day duration in the vicinity of the graft, with no associated symptoms. His oral temperature was 98.7-degrees-F and his blood pressure 150/95 mm Hg. He did not appear systemically ill. There was no swelling, fluctuance, heat, or erythema over the graft or in the surrounding tissues, although there was some poorly localizable tenderness, and a strong bruit and palpable thrill were present. There was no lymphadenopathy, and examination of the heart, lungs, and abdomen was unremarkable. The predialysis white blood cell count was 9600 with 82% neutrophils, 17% lymphocytes, and 1% eosinophils. Two sets of blood cultures were obtained, 1000 mg of vancomycin was administered IV after the completion of the dialysis treatment, and the patient returned home.