Renal arteriovenous (AV) fistula is an unusual but well-known complication of nephrectomy.1,2 Rarely, bacterial endarteritis may complicate an acquired AV fistula, giving rise to a clinical picture similar to that of bacterial endocarditis. [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] This report presents a case of successfully treated staphylococcal endarteritis in a renal AV fistula 19 years following nephrectomy.
Patient SummaryA 42-year-old white man was admitted to a local hospital on June 5, 1970, because of the sudden onset of chills and fever. Examination at the time of admission revealed a temperature of 104 F (40 C) and a soft systolic ejection murmur along the left sternal border. A blood culture was positive for coagulase-positive Staphylococcus aureus. The patient was treated with cephaloridine, sulfamethoxazole, and ampicillin sodium, but his fever continued. There was no history of rheumatic fever, scarlet fever, or heart disease. In 1951, the patient underwent nephrectomy on the left for hydronephrosis caused by aberrant renal vessels and had had no genitourinary problem since then. In 1968, the patient ex¬ perienced an acute febrile illness similar to the current episode, but this subsided within two days following a single in¬ jection of penicillin G procaine.On June 13, 1970, the patient was trans¬ ferred to the Minneapolis Veterans Ad¬ ministration Hospital. The man appeared to be acutely ill. The temperature was 104 F, the blood pressure 130/60 mm Hg, and the cardiac rate 110 beats per minute. The skin was warm and without a significant lesion. The neck veins were flat. The lungs were clear to auscultation. The first and second cardiac sounds were normal. There was a grade 2/6 systolic ejection murmur at the second left intercostal space. There was no diastolic murmur or gallop sound. The liver and spleen were not enlarged. The peripheral arterial pulses were bound¬ ing. There was no splinter hemorrhage. A loud, grade 4/6 continuous bruit with systolic accentuation was heard in the left flank with radiation to the left anterior portion of the midabdomen. Moderate ten¬ derness was found on percussion of the left flank.The hemoglobin level was 13.4 gm/100 ml. The leukocyte count was 13,400/cu mm with 95% neutrophils. The urine contained a trace of protein and 0 to 5 red blood cells per high-power field. The blood urea nitro¬ gen and serum electrolyte levels were nor¬ mal. The x-ray film of the chest was nor¬ mal. The electrocardiogram showed sinus tachycardia and counterclockwise rotation of the QRS loop. Five blood cultures ob¬ tained daily from the antecubital vein were positive for coagulase-positive S aureus, and resistant to penicillin, but sen¬ sitive to many other antibiotics, including oxacillin sodium add nafcillin sodium.The clinical diagnosis of an infected re¬ nal AV fistula was made. The patient was treated with intravenously administered nafcillin sodium, 3 gm every 12 hours for two weeks, following by intravenously ad¬ ministered oxacillin sodium for three weeks....
