Download Peritoneal Dialysis Peritonitis: Common Presentation by an

Advances in Peritoneal Dialysis, Vol. 30, 2014
Prashant Kolar, Prasad Bichu, Ramesh Khanna
Peritonitis remains a leading complication of peritoneal dialysis (PD). About 18% of the infection-related
mortality in PD patients is a result of peritonitis. We
present a case of peritonitis in a patient on automated
PD in whom the infection was not related to a break
in PD technique, but to an unusual cause: retrograde
transmission of a gonococcal organism.
Key words
Peritonitis, gonococcal infection
Introduction
Peritonitis remains the major complication of peritoneal dialysis (PD), contributing to significant morbidity. About 18% of infection-related mortality in PD
patients is related to peritonitis (1). Peritonitis has a
significant influence on peritoneal membrane characteristics, leading to PD failure. The spectrum of usual
organisms is small, but sometimes rare organisms gain
access to the peritoneal cavity. We present a case of
peritonitis in a patient on automated PD (APD) in
whom the infection was not related to a break in PD
technique, but to an unusual cause.
Case description
A 20-year-old woman presented with abdominal
pain of 1 weeks’ duration. The patient had been
noncompliant with her PD for 10 days, and when she
resumed therapy, she noticed cloudy PD effluent.
She had generalized weakness, poor appetite, and
abdominal pain, but no diarrhea or oozing from the
PD catheter exit site.
Past medical history consisted of end-stage renal
disease secondary to Alport disease, with PD start in
June 2012. Her APD prescription consisted of 1.5%
From: Department of Medicine, Division of Nephrology,
University of Missouri–Columbia, Missouri, U.S.A.
Peritoneal Dialysis
Peritonitis: Common
Presentation by an
Uncommon Organism
glucose solution (fill volume: 2000 mL) in 6 cycles
over 9 hours. She did not use long day dwells. She
still had a good amount of urine output (approximately
700 mL daily). She had experienced 1 episode of PD
peritonitis in June 2013, but the organism was not
detected, and the infection responded to intraperitoneal
vancomycin and ceftazidime.
Other significant history included deafness, anemia of end-stage renal disease, and secondary hyperparathyroidism. She had no visual defects. Her home
medications included calcitriol, ferrous sulphate, alfa
erythropoietin, phosphate binders, and oral furosemide for volume control. Health information for her
biologic parents was not available. The patient was
married and sexually active with her husband. No
history of substance abuse was present. She reported
intermittent menstrual spotting, the last episode having
occurred 3 months earlier.
Physical examination was unremarkable except for
diffuse abdominal tenderness. The PD catheter exit site
was clean. The effluent analysis showed a cell count
of 81,000, with 89% neutrophils. Gram stain showed
gram-negative diplococci. Considering the microbiology report, gonococcal peritonitis was diagnosed. The
original loading dose of vancomycin and ceftazidime
was then tailored to monotherapy with ceftazidime.
On further questioning, the patient reported having
had unprotected sex 2 weeks before her peritonitis.
She denied any pelvic complaints, including vaginal
discharge, pelvic pain, or bleeding per vagina.
Discussion
The most common source of peritonitis in PD patients
is contamination at the time of PD fluid exchange.
Such infections are commonly caused by staphylococci from skin. Other common routes of bacterial
entry include extension of infection from the exit site,
an enteric source, or hematogenous seeding. Gonococcal infection covers a broad disease spectrum that
Kolar et al.
includes asymptomatic infection, cervicitis, urethritis,
anorectal infection, pelvic inflammatory disease, and
disseminated gonococcemia. A disseminated infection
can seed into the peritoneum, but the affected patients
typically exhibit systemic symptoms, including fever,
chills, dermatitis, tenosynovitis, and polyarthralgia.
Our patient did not show any such symptoms.
Another route of infection in PD peritonitis is
ascending infection from the pelvic organs. This
possibility is restricted to women because of the
unique nature of the pelvic peritoneum. The ovarian
end of the fallopian tubes opens into the abdominal
peritoneal cavity, potentially providing a route for the
entry of organisms that can cause peritonitis. Retrograde menstruation is a well-known phenomenon
and has been reported in menstruating PD patients.
Blumenkrantz et al. (2) noticed cyclical hemoperitoneum among menstruating continuous ambulatory
PD patients, suggesting that retrograde menstruation
occurs despite the patient being on PD. Several case
reports have described leakage of peritoneal fluid
into the vagina, providing more evidence of open
communication between the peritoneal cavity and
the vagina (3–5). An ascending infection can result
in peritonitis caused by vaginal flora, including yeasts
(6–9). The risk seems to be especially higher after
vaginal instrumentation or the use of intrauterine
contraceptive devices (10). In our patient, an ascending infection from the vagina was a potential source
of her peritonitis.
Summary
Patients should be educated about safe sexual practices. Preventive care should include information on
contraceptive methods, with an emphasis on preventing sexually transmitted diseases. Barrier methods
are preferable. Intrauterine contraceptives should be
avoided because of the risk of pelvic inflammatory
disease (10). The role of hormonal contraception
in preventing pelvic inflammatory disease is controversial. Tubal ligation can potentially prevent
ascending infections, but a theoretical risk remains
because of the potential for spontaneous recanalization of the fallopian tubes. Sexually active women
should undergo routine cervical cancer screening.
Patients should seek prompt medical advice for any
symptoms of pelvic inflammatory disease. Sexual
partners should also be screened to prevent recurrence of infections.
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Our patient was successfully treated with 2 weeks
of intraperitoneal ceftazidime. She was also given a
course of oral doxycycline to cover for possible coexisting chlamydial infection in accordance with the 2010
guidelines from the U.S. Centers for Disease Control
and Prevention on the management of gonococcal
infections (11) and was advised to consult with an obstetrician/gynecologist for a pelvic exam. The patient
refused HIV testing and did not pursue a pelvic exam.
Our case highlights the need for nephrologists to be
alert to the possibility of sexually transmitted diseases
in their PD patients and particularly to the possibility
that organisms of the female genital tract can cause
peritonitis, which can potentially be recurrent.
Disclosures
The authors have no financial conflicts of interest
to disclose.
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PD Peritonitis with an Uncommon Organism
Corresponding author:
Prashant Kolar, md, University of Missouri–Nephrology,
One Hospital Drive, CE422, Columbia, Missouri
65212 U.S.A.
E-mail:
[email protected]