Abstract Background Infective endocarditis carries high mortality in hemodialysis patients, particularly when caused by methicillin‑resistant Staphylococcus aureus . Concomitant fungemia further worsens prognosis but remains rare. Case summary A 52‑year‑old woman with type 2 diabetes mellitus and stage V chronic kidney disease on thrice‑weekly hemodialysis presented with atypical chest pain, fatigue, night sweats, and splinter hemorrhages. She was afebrile. Transthoracic echocardiography showed preserved left‑ventricular ejection fraction and grade II mitral/tricuspid regurgitation; transesophageal echocardiography revealed a 0.7 × 2.1 cm pedunculated vegetation on the septal leaflet of the tricuspid valve. Three sets of peripheral and catheter blood cultures were drawn, and empiric renally adjusted daptomycin plus gentamicin were started. On day 3, C‑reactive protein had fallen. Cultures grew methicillin‑resistant Staphylococcus aureus in two peripheral sets and in the tunneled catheter, and Candida tropicalis in one peripheral set. The infected catheter was removed and a brachio‑axillary graft was placed. Gentamicin was discontinued; daptomycin was continued for six weeks. Voriconazole was administered for 21 days, ending 14 days after negative fungal cultures. Follow‑up echocardiography at week 6 showed complete resolution of the vegetation. The patient remained asymptomatic at three‑month follow‑up. Conclusion In immunocompromised hemodialysis patients, dual bacterial‑fungal bloodstream infections can occur, yet not every positive fungal culture indicates endocardial involvement. Serial cultures, prompt removal of infected hardware, and targeted antimicrobial therapy can achieve cure without surgery even in the presence of sizable vegetations.
Yilmaz et al. (Wed,) studied this question.