Infective endocarditis (IE) complicated by non-immune hemolytic anemia is a rare but clinically significant presentation, particularly in native valve disease, and often reflects severe valvular destruction leading to mechanical red blood cell fragmentation. Patients with end-stage renal disease (ESRD) on hemodialysis are at increased risk of bloodstream infections due to chronic vascular access, making early recognition essential. We report the case of a 36-year-old man with ESRD on hemodialysis via an arteriovenous (AV) graft who presented with acute dyspnea, hypoxia, and severe transfusion-refractory anemia. Laboratory evaluation revealed non-immune hemolytic anemia consistent with mechanical destruction. Blood cultures grew Streptococcus gordonii. Transesophageal echocardiography confirmed IE, demonstrating aortic valve vegetations with severe aortic regurgitation. His hospital course was further complicated by community-acquired pneumonia and acute hypoxic respiratory failure. The hemolytic process resolved after management with targeted intravenous antibiotics and urgent bioprosthetic aortic valve replacement. This case highlights the importance of considering subacute IE in patients with ESRD who present with persistent, unexplained hemolytic anemia, particularly in the setting of chronic vascular access. Early diagnosis and prompt intervention are critical to reducing morbidity and mortality associated with this uncommon but life-threatening complication.
Nguyen et al. (Mon,) studied this question.