Metastatic methicillin-resistant Staphylococcus aureus infection with infective endocarditis, pulmonary septic emboli, axillary abscess with a subacute presentation in a patient with chronic end-stage kidney disease on maintenance haemodialysis

A male adult patient on maintenance haemodialysis due to end-stage diabetic nephropathy presented with low-grade intermittent fever, cough and generalised weakness for 3 weeks. Initial blood investigations revealed an elevated neutrophil count with raised inflammatory markers. Chest CT revealed loculated hydropneumothorax with multiple cavitary nodules. Repeated blood cultures from the cuffed tunnelled catheter site and the right arm and sputum cultures were negative for pyogenic bacteria and yeast aetiology. The patient complained about left axillary pain on the fourth day of admission. Ultrasound-guided percutaneous aspiration from an axillary focal collection and subsequent culture revealed a methicillin-resistant Staphylococcus aureus (MRSA) infection. Echocardiography detected multiple vegetations on the tricuspid valve. The patient responded clinically to vancomycin and removal of the permanent catheter. This was a case of a tunnelled catheter-related metastatic MRSA infection with infective endocarditis, pulmonary septic embolism with a subacute presentation, and repeated blood culture negativity.