Case Presentation: A 79-year-old male presented after a fall approximately twelve hours prior. His medical history included 95% stenosis of the distal left anterior descending (LAD) artery, type II diabetes mellitus, and hypertension. Initial labs revealed glucose 682 mg/dL, CPK 2,428 U/L, troponin 4,045 ng/L, BUN 31 mg/dL, creatinine 1.9 mg/dL, and positive urine myoglobin. Blood pressure was 220/120 mmHg with blurry vision. Nicardipine, heparin, and insulin infusions were started. He was admitted to the intensive care unit (ICU), and percutaneous coronary intervention (PCI) to the LAD artery was performed via right radial access without immediate complications. Forty-eight hours post-procedure, he developed abrupt fevers (40°C), worsening confusion, chills, and diffuse extremity rigidity. He denied chest pain, respiratory symptoms, gastrointestinal complaints, or urinary symptoms. Chest radiograph, urinalysis, and liver function tests were unremarkable; leukocyte count remained normal and renal function improved to a creatinine 1.2 mg/dL. Blood cultures grew Klebsiella species, and ceftriaxone was initiated.Within 24 hours, he developed marked swelling and tenderness of the right upper extremity from axilla to wrist, consistent with phlebitis at the radial access site and the presumed source of bacteremia. Over the next several days, the patient’s fevers and confusion resolved, and phlebitis of the arm began to improve. By post-procedure day six, he was afebrile and clinically stable. He was discharged on a seven-day course of levofloxacin.
Discussion: PCI and coronary catheterizations have drastically increased in frequency over the past few decades. PCI is performed under sterile technique, with infections remaining a rare but important complication. A prior study revealed 18% of PCI patients had positive blood cultures immediately following the procedure, and 12% had positive blood cultures 12 hours later. However, many of these cases were asymptomatic and clinically insignificant.1 A large cohort of 22,006 invasive cardiologic procedures reported clinically significant bloodstream infection after diagnostic cardiac catheterization in only 9 of 14,034 cases.2Several factors increase the risk of clinically significant bacteremia, including advanced age, heart failure, repeated vascular access, prolonged sheath dwell times, and poor local site hygiene.3 This case demonstrates that even radial access PCI, while generally associated with fewer vascular complications, can still serve as a portal for infection when soft-tissue inflammation develops. In this case, the patient’s age, comorbidities, and development of access-site phlebitis likely contributed to the onset of Klebsiella bacteremia.Additionally, there are important implications for prevention. A recent large meta-analysis demonstrated a marked reduction in catheter-related bloodstream infections with the use of antibiotic-impregnated or heparin-coated vascular catheters.4 While not routinely used for coronary access, this data highlights evolving opportunities to further minimize infectious risk in high-risk populations undergoing PCI.
Conclusions: This case emphasizes the importance of maintaining a broad differential for fever after PCI and integrating careful inspection of vascular access sites into routine post-procedure evaluation. As older and more comorbid patients undergo PCI, recognizing catheter-associated infections early remains essential to prevent sepsis and reduce morbidity.