International Journal of Clinical Medicine, 2012, 3, 433-437 Published Online September 2012 ( 1
A Fatal Complication of a Peripheral Venous Catheter*#
Lenneke E. M. Haas1, Bart C. Kortlandt1, Steven F. T. Thijsen2,3, Jan-Willem Fijen1,
Sanjay U. C. Sankatsing4
1Department of Intensive Care Medicine, Diakonessenhuis, Utrecht, The Netherlands; 2Department of Cardiothoracic Surgery, Uni-
versity Medical Center Utrecht, Utrecht, The Netherlands; 3Department of Microbiology, Diakonessenhuis, Utrecht, The Netherlands;
4Department of Internal Medicine, Diakonessenhuis, Utrecht, The Netherlands.
Received May 31st, 2012; revised June 30th, 2012; accepted July 16th, 2012
Peripheral venous catheters (PVC) are widely used in the hospital and seem to be innocent. However, complication s can
be devastating. We present a case of a fatal septic shock due to vertebral osteomyelitis after PVC-rela ted St aph yloc occu s
aureus bacteremia (SAB). Staphylococcus aureus is a leading cause of bacteraemia in both the community and the hos-
pital with a significantly increased in cidence over the last several decades. Intravascular catheters are the most common
cause of SAB. Morbidity and mortality are high, even with appropriate therapy. Although complications are known and
common, they may be difficult to recog nize. Vertebral osteomyelitis is one of these known severe complications.
Keywords: Staphylococcus Aureus Bacteraemia; Vertebral Osteomyelitis; Peripheral Venous Catheter; Intensive Care
1. Introduction
Staphylococcus aureus is a leading cause of bacteraemia
and its incidence is still increasing. Predisposing factors
of S. aureus bacteraemia (SAB) are older age, intr avasc u-
lar catheters, wounds, needle use, co morbid illnesses
(diabetes mellitus, respiratory illness, malignancy) and
the use of immunosuppressive drugs [1,2]. Intravascular
catheters are the most common cause of SAB [3].
Complications of SAB are common, but may be diffi-
cult to recognize. Persistent fever and positive follow-up
blood cultures 48 to 96 hours after starting antibio tics are
predictive for subsequent complications [4]. Prior to the
discovery of antibiotics, SAB was fatal in more than 80%
of cases [5]. Nowadays, its mortality rate is still over
20% [6-8].
Hematogenous spread is the most frequent cause of
osteomyelitis and lumbar vertebral bodies are most often
involved [ 9]. Alth ough th e disc space has no d irect blood
supply, it can become secondary involved [10].
The incidence of vertebral osteomyelitis is about
1:350,000 and has steadily increased during recent years
probably as a consequence of the increasing rates of
nosocomial bacteraemia due to intravascular devices and
other forms of instrumentation, increasing age of the
population and more injection drug use [11]. The major-
ity of the patients are older than 50 years of age, whereas
men are affected approximately twice as often as women
[12]. Vertebral osteomyelitis (also named spinal osteo-
myelitis, spondylodiscitis, septic discitis, or disc space
infection) is a known severe complication of Staphylo-
coccus aureus (S. aureus) bacteraemia (SAB) which ac-
counts for more than 50 percent of cases. Other patho-
gens include Enteric Gram-negative bacilli, Pseudomo-
nas aerugino sa, Candida spp., Gr oups B and G hemolytic
streptococci and Mycobacterium tuberculosis [13].
Pain is the major sympto m, fever occurs inco nsistently.
The majority of patients have an elevated C-reactive
protein (CRP) and erythrocyte sedimentation rate (ESR),
leucocytes can be elevated or normal [14]. Blood cultures
are positive in up to 50 to 70 percent of patients [15].
Standard radiographic imaging often remain normal in
the early phases. Computed tomography (CT) can show
typical or suggestive changes in an earlier phase, al-
though subtle abnormalities may be missed. Magnetic
resonance imaging (MRI) is the most sensitive radiologic
technique for vertebral osteomyelitis although, 18F-fluo-
rodeoxyglucose-positron emission tomography (PET) is
a new promising tool [16]. The diagnosis can be con-
firmed by culture of the intervertebral discus or vertebral
bone tissue. However, when blood cultures from a pa-
tient with compatible clinical and radiographic findings
reveal a likely pathogen, a biopsy is not necessary [15].
Antibiotic therapy should be guided by culture results
including susceptibility testing. Parenteral antibiotics are
recommended [13]. The optimal duration of antibiotic
*None of the authors has a conflict of interest to declare.
#All authors contributed to the writing of this case report and they all
approved the final version.
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A Fatal Complication of a Peripheral Venous Catheter
treatment is still not completely determined. Although
most patients respond to antimicrobial therapy, surgery
may be necessary in some patients.
We present a case of a fatal septic shock due to verte-
bral osteomyelitis after a peripheral venous catheter
(PVC)-related SAB. Although SAB is not uncommon,
we think this case is informative, because it illustrates
that a simple and widely used PVC can have devastating
complications, even when adequately treated.
2. Case Presentation
A 75-year-old woman was admitted to the orthopedic
ward because of severe back pain. Her medical history
revealed multiple osteoporotic vertebral fractures. CT-
imaging of the spine showed an osteoporotic fracture of
the 11th thoracic vertebral body (see Figure 1(a)), for
which she received oral analgesics and a back bracing.
Three days after admission, she collapsed and was trans-
ferred to our ICU. Clinical examination showed severe
hypotension and a newly developed partial paraplegia.
She was resuscitated with fluids and a vasopressor under
the suspicion of a neurogenic shock due to spinal com-
The initial laboratory results are shown in Table 1.
A MRI was performed, demonstrating a considerably
decreased and increased signal intensity of both the 10th
and 11th thoracic vertebral body and a partial compres-
sion of the myelum at this level on respectively T1 and
T2 weighted images (see Figures 1(b) and (c)).
Subsequently a laminectomy and spondylodesis was
performed to relieve the compressed spinal cord.
A review of the patient medical history revealed a
PVC-related SAB 3 months before which was treated
with intravenous flucloxacillin for two weeks. Because
of the suspicion of a pyogenic osteomyelitis, high dose
intravenous flucloxacillin (12 gram/day) was started.
Gentamicin was initially added, but was stopped after
two days. S. aureus was cultured from both blood and
from the vertebral disc and paravertebral fatbiopsies.
Since at this point an endo carditis was considered a tran-
sesophageal echocardiography (TEE) was performed
which showed no signs of endocarditis. Peroperatively
taken biopsies of the affected vertebral body showed
chronic inflammation.
Although initial hemodynamic improvement was seen
and signs of partial paraplegia decreased, her clinical
condition worsened in the follow ing days. She develop ed
multiple organ dysfunction syndrome (MODS) with he-
moynamic, respiratory, renal and intestinal failure and
disseminated intravascular coagulation (DIC). Because
of the progressive MODS and in view of her poor per-
formance state previously, it was decided to withdraw
life sustaining treatment. She deceased soon thereafter.
(b) (c)
Figure 1. (a) CT-image of the spine showing a new osteo-
porotic fracture of the 11th thoracic vertebral body with
bone fragments in the vertebral space and a paravertebral
hematoma; (b) T1-weighted MRI image, showing low signal
intensity at level Th10-Th11, suspected for fracture with
edema, metastasis or infection; (c) T2-weighted MRI image,
showing a considerably increased signal intensity of both
the 10th and 11th thoracic vertebral body and a partial
compression of the myelum at this level; (d) Autopsy pho-
tograph showing a part of the colon with greenish coating
and a large ulceration.
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A Fatal Complication of a Peripheral Venous Catheter
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Table 1. Laboratory results on admission to the ICU.
Leucocytes count 1.73 × 1010/L 4.0 - 10.0 ×109/L
C-reactive protein (CRP) 126 mg/L <10 mg/L
Sodium 131 mmol/L 135 - 145 mmol/L
Potassium 4.6 mmol/L 3.5 - 5.0 mmol/L
Urea 23 mmol/L 2.5 - 6.4 mmol/L
Creatinin 270 µmol/L 44 - 80 µmol/ L
Gamma- glutamyl transferase (GGT) 108 U/L <35 U/lL
Alkaline phosphatase (ALP) 256 U/L 35 - 120 U/L
Alanine aminotransferase (ALT) 57 U/L <45 U/L
Aspartate aminotransferase (AST) 130 U/L <40 U/L
Lactase dehydrogenase (LDH) 397 U/L <220 U/L
Amylase 616 U/L <100 U /L
Lactate 10.3 mmol/ L 0.5 - 2.2 mmol/L
Albumin 29 g/L 35 - 55 g/L
pH 7.18 7.35 - 7.45
pCO2 4.7 kPa 4.7 - 6.4 kPa
pO2 17.9 kPa 10.0 - 13.3 kPa
Bicarbonate 12.8 mmol/L 22 - 29 mmol/L
Autopsy was performed and revealed an ischemic l arge
intestine with ulcerations and vascular microthrombi (see
Figure 1(d)). Ischemia was thought to be due to the
combination of DIC with high dose nor adrenalin. Further
determination of the S. aureus was performed and it ap-
peared to be an enterotoxin B producing Panton Valen-
tine Leucocidin (PVL) negative strain which might at
least partially explain the pathologic findings of the large
intestine. During autopsy no signs of endocarditis were
found either.
3. Discussion
PVC-related SAB is still an under recognized complica-
tion. As presented in our case, this may have catastrophic
consequences, even when adequately treated.
What can we learn from this case? In retrospect, the
initial treatment might not have been adequate. Since a
purulent trombophelitis was present, a complicated SAB
should have been suspected and more than two weeks of
intravenous therapy should have been considered [17].
Unfortunately, no follow-up blood cultures after initia-
tion of treatment were taken and no TEE was performed.
If these cultures were taken and found po sitive, or in case
of development of complications, therapy indeed should
have been continued. Adherence to diagnostic and thera-
peutic guidelines of SAB still seems to be insufficient
[18]. It has been demonstrated that consultation of an
infectious disease specialist in case of a SAB results in
more frequent detection of endocarditis and metastatic
infection [19]. In our hospital we have a protocol in
which every patient with a SAB is consulted by a resi-
dent internal medicine under supervision of an infectious
disease specialist or microbiologist. Unfortunately, in
this case the protocol was not followed and there had
been no consultation.
In addition, there was a critical delay in diagnosis
since the complaints of ba ck pain were initially attrib uted
to the known degenerative spinal disease, whereas verte-
bral osteomyelitis was not considered despite multiple
positive blood cultures with S. aureus three months ear-
4. Conclusion
In this patient, a pyogenic vertebral osteomyelitis with
catastrophic consequences developed due to a PVC re-
lated SAB. This case illustrates that even a simple and
widely used item as a PVC can cause serious complica-
tions and that in case of a SAB consultation of an infec-
tious disease team might be beneficial. Furthermore, in
our opinion, all patients with a SAB, even when a com-
plicated infection is ruled out, should be instructed to
contact a physician in case of fever or other signs that
might suggest a metastatic infection.
5. Summary of Key Points
Peripheral venous catheters (PVC) are widely used in
hospitals and seem very innocent. However complica-
tions can b e d evastati ng.
A Fatal Complication of a Peripheral Venous Catheter
Staphylococcus aureus is leading cause of bacte-
raemia in both the community and the hospital and
the incidence is still increasing. Intravascular cathe-
ters are the most common cause of SAB.
SAB has a high morbidity and mortality, even with
appropriate therapy. Endocarditis and vertebral osteo-
myelitis are two serious complication s of SAB.
A minimum of two weeks of parenteral antibiotic
therapy should be given and follow-up blood cultures
should be ta ken.
Consultation of an infectious disease specialist seems
of great additive value.
6. Acknowledgements
The authors would like to thank Dr. L. Wijnaendts, pa-
thologist and L. Sibinga Mulder, radiologist, both from
the Diakonessenhuis Utrecht, for their contribution to
this case report.
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A Fatal Complication of a Peripheral Venous Catheter
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PVC: Peripheral venous catheter
SAB: Staphylococcus aureus bacteraemia
CRP: C-reactive protein
ESR: Erythrocyte sedimentation rate
CT: Computed tomography
MRI: Magnetic resonance imaging
PET: Positron emission tomography
TEE: Transesophageal echocardiography
MODS: Multiple organ dysfunction syndrome
DIC: Dissem inate di ntravascular coagul ati on
PVL: Panton Valentine Leuco cidin