Sudden Vision Loss During Hemodialysis

Introduction Catheter-related blood stream infections (CRBSIs) are a common and unfortunate consequence of prolonged vascular access in hemodialysis patients. Metastatic infections are feared sequelae of bacteremia, and include endocarditis, osteomyelitis, septic arthritis, epidural abscess, and endophthalmitis.1 The following is a case of Serratia endophthalmitis originating from a tunneled-dialysis catheter. Case Presentation A 47 year-old Caucasian female with a history of end stage renal disease on hemodialysis, Type 2 diabetes mellitus, and hypertension was undergoing her routinely scheduled hemodialysis session when she experienced “flashes of hot pink” in her left eye. The hemodialysis session was terminated, and the patient returned home. When she awoke the next morning she noticed a large black spot obscuring vision in her left eye as well as pain in the affected eye. The patient presented to Wills Eye Emergency Department that day. She denied any recent fevers, chills, pain, or erythema at the catheter site. She did, however, report that her left-sided chest wall tunneled dialysis catheter had been manipulated and tubing had been exchanged the day prior because of concerns that it was clogged. The patient was transferred to Thomas Jefferson University Hospital (TJUH) for further care. Initial vital signs revealed a temperature of 98.6 degrees Fahrenheit, heart rate of 88 beats per minute, respiratory rate of 21 per minute, blood pressure of 160/94 mmHg, and 95% oxygen saturation on room air. Physical exam was significant for a diffusely erythematous left sclera with a hazy cornea and a small hypopion occupying the bottom third of the pupil (Figure 1). Her left pupil was sluggishly reactive to light. The patient’s visual acuity exam of the left eye revealed 20/60 vision (20/20 in right eye). Her left chest wall port site was non-erythematous with no palpable fluctuance or drainage. There was no tenderness to palpation in this area. Cardiac exam revealed a grade II/VI systolic ejection murmur most prominent at the right upper sternal border. There were crackles at both lung bases and bilateral 2+ lower extremity pitting edema to the shins. There were no splinter hemorrhages or other skin changes. The patient’s admission laboratory values were notable for a white blood cell count of 16,200 cells/microliter (normal range 4,000-11,000) with 92% neutrophils (normal range 40-73%) and a hemoglobin of 7.5 g/dl (normal 12.5-15) decreased from a baseline of 9 g/dl. A chest x-ray was normal