Recurrent Invasive Staphylococcus aureus Infections in a Non-Neutropenic Hemodialysis Patient With Myelodysplastic Syndrome: A Case Report.

INTRODUCTION

Myelodysplastic syndromes (MDS) may be overlooked in patients undergoing hemodialysis (HD) because anemia is commonly attributed to renal anemia and treated with erythropoiesis-stimulating agents. MDS is also associated with an increased risk of bacterial infections due to neutropenia and qualitative immune dysfunction. We report recurrent invasive methicillin-susceptible Staphylococcus aureus (MSSA) infections in a patient undergoing HD with concomitant MDS.

CASE PRESENTATION: The patient was a 76-year-old man undergoing HD for end-stage kidney disease due to nephrosclerosis who was referred to our hospital because of persistent anemia despite high-dose darbepoetin alfa therapy. He had a history of CHOP therapy for diffuse large B-cell lymphoma, and his MDS was considered possibly therapy related. Bone marrow aspiration revealed trilineage dysplasia and 3.4% blasts without chromosomal abnormalities, leading to a diagnosis of MDS with multilineage dysplasia. Approximately 1 year later, he developed persistent fever. Blood cultures yielded MSSA, and imaging studies revealed septic pulmonary embolism and multiple cerebral infarctions. He improved after intravenous cefepime therapy. Twenty-two months later, he developed fever and left shoulder pain. Contrast-enhanced computed tomography revealed an abscess in the left subscapularis muscle, and MSSA was isolated from the drainage fluid after CT-guided drainage. He improved with drainage and antibiotic therapy. In both episodes, the neutrophil count was preserved.

CONCLUSION

This case illustrates recurrent invasive MSSA infections in a non-neutropenic HD patient with possibly therapy-related MDS. HD-related factors should be carefully evaluated as common causes of recurrent S. aureus infection, and MDS may represent an additional, unproven host factor. MDS should be considered in ESA-resistant anemia in HD patients, particularly in those with a history of cytotoxic chemotherapy.