Recurrent Septic Pulmonary Embolization Complicating Maintenance Hemodialysis

Recurrent episodes of septic pulmonary embolization are described in three patients undergoing maintenance hemodialysis. Abnormalities of serum bilirubin, alkaline phosphatase, and serum glutamic-oxalacetic transaminase were observed in two patients and pericarditis with effusion and atrial fibrillation in one patient. Serial chest roentgenograms showed one or more small areas of infiltration in the peripheral lung fields. There was no correlation between gross evidence of local infection and the occurrence of septic pulmonary embolization. Hemodialysis treatments were often associated with an exacerbation of the clinical picture, suggesting infection in the region of the arteriovenous shunt as the cause. Once septic pulmonary emboli recurred in the same individual, antibacterial therapy was ineffective. The clinical course in these patients suggested that the indwelling foreign body—the arteriovenous shunt—was responsible for the poor response to antibiotics. The recommended treatment for recurrent septic pulmonary embolization complicating maintenance hemodialysis is removal of the shunt and control of systemic infection. Recannulation should be performed in a different extremity only after all signs of systemic infection have resolved.