Peritoneal dialysis related peritonitis due to Mycobacterium spp.: A case report and review of literature

Tuberculous peritonitis in patients on peritoneal dialysis: a 35-year experience from a large medical center in Northern Taiwan

INTRODUCTION

Tuberculous peritonitis (TBP) is a rare but fatal complication in patients on peritoneal dialysis (PD). In this study, we aimed to determine the demographic features, clinical features, laboratory parameters, and clinical outcomes of PD patients with TBP and to clarify possible risk factors for mortality.

MATERIALS AND METHODS

We retrospectively reviewed 2084 PD patients from January 1985 to December 2019. The diagnosis of TBP was established by positive peritoneal fluid culture for Mycobacterium tuberculosis.

RESULTS

18 patients were diagnosed with TBP. The incidence was 2.029 episodes per 1000 patient-years. The most common symptom was fever (94.4%), followed by cloudy effluent (83.3%) and abdominal pain (83.3%). The average peritoneal dialysis effluent (PDE) white blood cell (WBC) count was 172.7 cells/μL. Nine patients (50%) had WBC counts lower than 100 cells/μL and 13 patients (72.2%) had neutrophilic predominant WBC counts. Acid fast stain (AFS) was positive in 7 patients (38.9%). Only 2 patients (11.1%) continued with PD after TB infection, while 10 patients (55.6%) changed to hemodialysis. Seven patients (38.9%) died within 1 year. Significant differences were observed in sex (p = 0.040), the presence of diabetes mellitus (p = 0.024), and PD catheter removal (p < 0.001) between TBP patients with and without mortality. However, none of them was a significant factor for 1-year mortality in multivariate Cox regression model.

CONCLUSION

Physicians should pay attention to the unusual presentations of peritonitis, especially if symptoms include fever or an initial low PDE WBC count. Catheter removal is not mandatory if early diagnosis and appropriate therapy are available.

Tuberculous Peritonitis in a Peritoneal Dialysis Paediatric Patient: A Case Report

Mycobacterium tuberculosis is known to cause infection primarily in the lungs, which may spread to other parts of the body causing extrapulmonary tuberculosis. Few studies in the literature identify M. tuberculosis as a cause of peritoneal dialysis (PD)-associated peritonitis among paediatric patients who have no history of pulmonary tuberculosis. PD is the most used renal replacement therapy for paediatric patients with end-stage renal disease. However, despite continuous improvements in the PD connecting system, peritonitis remains the Achilles’ heel of dialysis procedures and prophylaxis for PD. Here, we report a case of M. tuberculosis peritonitis in a paediatric patient receiving PD and the infection was managed successfully with appropriate anti-tuberculous treatment. This case emphasises the importance of considering tuberculous peritonitis in PD paediatrics patients who have no history of pulmonary tuberculosis and whose PD routine cultures produce negative results.

Peritonitis related to continuous ambulatory peritoneal dialysis due to Mycobacterium tuberculosis: A case report

Continuous ambulatory peritoneal dialysis (CAPD) has been an effective treatment for end-stage renal disease (ESRD). Tuberculous peritonitis (TBP) in patients on CAPD is a perilous condition. A 28-years-old female presented to the emergency unit with a chief complaint of intermittent abdominal pain and fever. The patient had a history of renal failure and CAPD was inserted. CAPD fluid analysis revealed leukocytes of +3/visual field and positive for acid-fast bacilli. The patient was given antituberculous agents, CAPD removal, and AV shunt installment for the subsequent HD access. A high index of suspicion must always be maintained for CAPD-associated tuberculous peritonitis.

A Saudi Arabian Public Health Perspective of Tuberculosis

Tuberculosis is a global health challenge due to its spreading potential. The Kingdom of Saudi Arabia (KSA) faces a challenge in the spread of tuberculosis from migrant workers, but the foremost threat is the huge number of pilgrims who travel to visit sacred sites of the Islamic world located in the holy cities of Makkah and Al Madina. Pilgrims visit throughout the year but especially in the months of Ramadan and Zul-Hijah. The rise of resistance in Mycobacterium tuberculosis is an established global phenomenon that makes such large congregations likely hotspots in the dissemination and spread of disease at a global level. Although very stringent and effective measures exist, the threat remains due to the ever-changing dynamics of this highly pathogenic disease. This overview primarily highlights the current public health challenges posed by this disease to the Saudi health system, which needs to be highlighted not only to the concerned authorities of KSA, but also to the concerned global quarters since the pilgrims and migrants come from all parts of the world with a majority coming from high tuberculosis-burdened countries.

A Rare Case: Tuberculous Peritonitis, Encapsulating Peritoneal Sclerosis, and Incisional Hernia in Continuous Ambulatory Peritoneal Dialysis Patient

BACKGROUND: Peritonitis is the most common infectious complication of peritoneal dialysis (PD) with an estimated ratio of 1:20–30 patients per month. In addition, less than 3% cases are due to Mycobacteria, although not all are caused by Mycobacteria tuberculosis. Therefore, specific examinations are needed for proper diagnosis. Encapsulating peritoneal sclerosis (EPS), another rare complication of PD, accounts for 0.7–13.6 per 1000 patients per year. CASE REPORT: A 37-year-old man undergoing PD, with complaints of intermittent abdominal pain and cloudy fluid, followed by nausea, vomiting, and constipation. Furthermore, visible protrusion was observed on the abdominal wall due to the wound from the Tenckhoff catheter insertion surgery. This is clearly comprehended as the patient sits or stands but disappears on lying down. Along with the condition, continuous ambulatory PD (CAPD) ultrafiltration ability decreases, rough defecation occurs, with a hard sensation on the lower right abdomen. Moreover, the patient had earlier suffered peritonitis for the 3rd time. The results of the dialysate fluid analysis showed a cloudy liquid coloration, as the number of cells 278, polymorphonuclear 87, mononuclear 13, Ziehl–Neelsen +1 and acid-resistant bacteria +3 staining, including GeneXpert MTB/RIF, were positive. Furthermore, abdominal computed tomography (CT) scan revealed a thick peritoneum, partly with calcification, air-filled intestinal, dilated colon with wall thickening. Furthermore, the mesentery lining the liver and intestine were observed to be dense with multiple calcifications to support an EPS. Definitive diagnosis is confirmed by laparotomy and/or laparoscopy, but CT scan provides an alternative. Subsequently, CAPD utilization is discontinued and switched to renal replacement therapy to hemodialysis twice a week due to several complications associated with PD, ranging from recurrent peritonitis, tuberculous peritonitis, EPS, and incisional hernias responsible for an ineffective PD ultrafiltration. CONCLUSION: At present, the combination of clinical symptoms, radiology, and medical pathology remains the key to diagnosing tuberculous peritonitis and EPS. Consequently, prompt and precise analysis determines a good prognosis.

Features of the pathogenetic mechanisms of tuberculous peritonitis in an experiment

The prevalence of tuberculous peritonitis that has been observed in the recent decades is the result of lymphohematogenous spread of Mycobacterium tuberculosis (MBT) from lungs and other extrapulmonary sources. It is still unclear why certain organs and anatomical regions get involved in the inflammatory process during generalization of the tuberculosis infection. Why do some cases develop into peritoneal tuberculosis and other into kidney tuberculosis? Thus study aimed to investigate the pathogenesis of tuberculous peritonitis in a reproducible biological model. Tuberculous peritonitis was modeled in 18 rabbits (10 in the test group, 8 in control) by intraperitoneal inoculation of the MBT suspension. In order to suppress peritoneal macrophages and major cytokines, test group rabbits were injected with the TNFα inhibitor and iron (III) hydroxide sucrose complex before being infected, while control group rabbits received no immunosuppressive drugs. Autopsy of the control group animals revealed changes characteristic of pulmonary tuberculosis in 37.5% of cases, with no damage to other organs and systems registered. Conversely, test group rabbits had the signs of tuberculous peritonitis in their abdominal cavities. The results of this study suggest that it is the local immunity of an anatomical area that largely determines whether a secondary focus of extrapulmonary tuberculosis infection will develop there or not. For the peritoneum, a smaller pool of peritoneal macrophages and weaker cytokine production is a necessary and sufficient condition to have tuberculous peritonitis developing therein.

Mycobacterium abscessus - an uncommon, but important cause of peritoneal dialysis-associated peritonitis - case report and literature review

BACKGROUND

Peritoneal dialysis (PD) is a form of therapy for end-stage kidney disease (ESKD), and peritonitis is a known complication. Mycobacterium (M) species associated peritonitis in PD patients is uncommon. Our experience of managing PD associated peritonitis caused by M abscessus in a middle-aged man with ESKD due to focal segmental glomerulosclerosis is shared in this article with a review of the literature on this condition.

CASE PRESENTATION

A 49-year old man presented to our unit with symptoms of peritonitis and cloudy PD effluent. Initial analysis of PD fluid showed Gram stain was negative, with no organism grown. Empirical PD peritonitis treatment with intra-peritoneal antibiotics did not improve his symptoms and he required intravenous antibiotics, PD catheter removal and a switch to haemodialysis. Cultures of the PD fluid later grew M abscessus, and the antibiotic regimen was changed appropriately, leading to clinical improvement.

CONCLUSION

M abscessus associated peritonitis in PD patients is rare. It needs to be borne in mind when clinical improvement is not seen with standard broad-spectrum antibiotics, especially in situations where the PD fluid is initially deemed to be culture negative. PD fluid samples should be sent for acid-fast bacillus and if detected, should be further analysed with genome-wide sequencing to confirm the species of the Mycobacterium. Prompt removal of the catheter with peritoneal washout is critical for clinical improvement.

Clearing the clouds: Case-report and review of the literature

In peritoneal dialysis (PD), a cloudy dialysate is an alarming finding. Bacterial peritonitis is the most common cause, however, atypical infections and non-infectious causes must be considered. A 46-year-old man presented with asthenia, paraesthesia, foamy urine and hypertension. Laboratory testing revealed severe azotaemia, anaemia, hyperkalaemia and nephrotic-range proteinuria. Haemodialysis was started through a central venous catheter. Later, due to patient preference, a Tenckhoff catheter was inserted. Conversion to PD occurred 3 weeks later, during hospitalization for a presumed central line infection. A month later, the patient was hospitalized for neutropenic fever. He was diagnosed an acute parvovirus infection and was discharged under isoniazid for latent tuberculosis. Four months later, the patient presented with fever and a cloudy effluent. Peritoneal fluid (PF) cytology was suggestive of infectious peritonitis, but the symptoms persisted despite antibiotic therapy. Bacterial and mycological cultures were negative. No neoplastic cells were detected. Mycobacterium tuberculosis eventually grew in PF cultures, despite previous negative molecular tests. Directed therapy was then initiated with excellent response. Thus, facing a cloudy effluent, one must consider multiple aetiologies. Diagnosis of peritoneal tuberculosis is hampered by the lack of highly sensitive and specific exams. Here, diagnosis was only possible due to positive mycobacterial cultures.

An unusual case of unresolving tunnel infection in a patient on continuous ambulatory peritoneal dialysis

Atypical mycobacteria remain a rare cause of peritoneal dialysis catheter-related tunnel infection (TI) and poses serious risk because of the resistant nature to most antibiotic therapy. Non-tubercular mycobacterial infections lead to chronicity requiring peritoneal dialysis catheter removal. We report an 82-year-old male, with diabetic nephropathy who had a coinfection with Staphylococcus hominis and Mycobacterium abscessus who presented with pus discharge at exit site and TI. He was treated with relocation of the extraperitoneal part of the catheter with a new exit site without catheter removal and multidrug mycobacterial therapy.

Diagnostic and Therapeutic Strategies for Peritoneal Tuberculosis: A Review

Peritoneal tuberculosis (PTB), although rarer than its pulmonary counterpart, is a serious health concern in regions of the world with high tuberculosis prevalence. Individuals with baseline immunocompromise condition, whether acquired or medically induced, are at greatest risk for experiencing PTB. While medical treatment of the condition is similar to that of the pulmonary disease, the generally immunocompromised state of those infected with PTB, along with a lack of highly sensitive and specific testing methods make early diagnosis difficult. This review discusses the risks factors, clinical features, diagnostic methods, and treatment options for PTB.

CUIDADO, DOENÇA E SAÚDE: REPRESENTAÇÕES SOCIAIS ENTRE PESSOAS EM TRATAMENTO DIALÍTICO

RESUMO Objetivo: analisar e comparar a estrutura representacional do cuidado com saúde e a doença entre pessoas em tratamento dialítico. Método: pesquisa qualitativa norteada na Teoria das Representações Sociais em sua abordagem estrutural, com 165 participantes, adultos, de ambos os sexos e tratamentos de hemodiálise e dialise peritoneal de quatro serviços de nefrologia em Curitiba e região. Os dados foram coletados entre junho de 2014 e maio de 2015, por meio das evocações livres aos termos indutores "cuidado com a doença" e "cuidado com a saúde" e tratados pelo software Ensemble de Programmes Pemettant L´Analyse des Evoctions e análise do quadro de quatro quadrantes. Resultados: os resultados revelam que as representações de cuidado com a saúde e a doença compartilham conteúdo da doença, mas possui organização distinta, a saúde com o enfoque dos hábitos de vida e dimensão biomédica e a doença ressalta o aspecto avaliativo. Conclusão: as representações de cuidado com a saúde e a doença interagem com comportamentos, atitudes e posicionamentos para o cuidado e fornece elementos para compreensão e apoio dos recursos individuais e ajustes da doença.