Abstract Introduction Catheter-related atrial thrombus (CRAT) is a known phenomenon in dialysis patients with indwelling catheters. However, there lacks a standardized management guideline given the complexity of individual cases. We describe the case of a patient with multi-focal pneumonia secondary to septic right atrial (RA) thrombus with positive antiphospholipid syndrome (APS) workup. Case Presentation 19-year-old female with end stage renal disease (ESRD) presented to ED from dialysis for sinus tachycardia in the 160’s. Initial work-up revealed leukocytosis of 16,000 with neutrophilic dominance, procalcitonin of 130 and multifocal pneumonia on CT chest. Patient developed new onset hypoxia a few days later despite timely initiation of vancomycin, cefepime and metronidazole. Further workup included a transesophageal echo (TEE) that revealed a 4.49 x 2.10 cm RA mass concerning for thrombus versus vegetation that extended into superior vena cava and prolapsed into right ventricle during diastole. Blood and wound cultures from all access sites were negative during this admission; however, several months ago, patient was noted to have an arteriovenous graft infection with Aggregatibacter species that was incompletely treated after leaving against medical advice (AMA). With this culture profile, antibiotics were changed to vancomycin and Ceftriaxone with concurrent initiation of heparin drip. Her clinical status improved rapidly afterwards. However, she left AMA with apixaban and oral antibiotics. A week later, patient presented to another facility with similar chief complaint. Cardiac MRI revealed reduction of RA mass size. Hypercoagulability workup revealed positive Beta-2 Glycoprotein-1 antibodies, concerning for APS. Warfarin was initiated. However, patient left AMA from the second facility as well. Discussion Past case reports demonstrated variable degrees of success with medical management or invasive retrieval of CRAT. Selection of antibiotics in our case was further complicated by the HACEK pathogen group that is known to exhibit fastidious growth and frequently evades traditional laboratory detection. Literature review reveals no current official recommendation on hypercoagulability workup as part of standard assessments for CRAT; there is no guideline on anticoagulation in the management of CRAT either, especially in hemodialysis patients. However, positive APS workup in our patient indicates that other prothrombotic factors may contribute to the development of CRAT in addition to the catheter-induced endothelial injury and hypercoagulability in ESRD patients. Timely recognition of infectious nidus and additional prothrombotic risk factor sheds light in early selection of appropriate antibiotics and anticoagulants. This abstract is funded by: None
Zhu et al. (Fri,) studied this question.