Recurrent Paraspinal Abscess and Persistent Bacteremia Complicated by Mitral Valve Endocarditis and Septic Embolic Stroke.

Patients with end-stage renal disease (ESRD) on hemodialysis are at high risk for infective endocarditis (IE), recurrent bacteremia, and embolic complications, with in-hospital, six-month, and one-year mortality rates exceeding those of the general population. This case involves a 62-year-old man with ESRD on hemodialysis who has a history of lumbar spinal fusion with hardware and a prior paraspinal abscess, who presented with septic shock and diffuse pain in the setting of recurrent polymicrobial multidrug-resistant bacteremia. The patient's hospital course was complicated by mitral valve IE and multifocal septic embolic strokes. Despite broad-spectrum antimicrobial therapy and percutaneous drainage of the abscess, source control was not achieved in this patient due to the inability to undergo surgical intervention. Cardiothoracic surgery recommended abscess control prior to mitral valve replacement; however, neurosurgery deemed him prohibitively high risk due to severe thrombocytopenia and persistent hypotension. With ongoing bacteremia and clinical deterioration, goals-of-care discussions resulted in DNR/DNI status and transition to comfort measures. This case underscores the unfavorable prognosis that IE carries in chronic hemodialysis patients and emphasizes the need for early diagnosis, aggressive efforts at source control, and timely multidisciplinary assessment for overall care and definitive surgical intervention.