Mycobacterium chelonae peritonitis in a patient on peritoneal dialysis

Systematic literature review of the diagnosis, prognosis, and treatment of peritoneal dialysis-related infection caused by nontuberculous mycobacteria

The number of peritoneal dialysis (PD) catheter-related infections and peritonitis caused by nontuberculous mycobacteria (NTM) has been increasing. Nonetheless, the optimal timing for the relocation of the exit site, removal and reinsertion of the PD catheter, prognosis, and duration of antibiotic treatment remain unclear. This literature review aimed to investigate the epidemiology of patient characteristics and evaluate the most effective diagnostic and treatment strategies for PD catheter-related infections and peritonitis caused by NTM. The systematic literature review was conducted on published cases of PD catheter-related infection and peritonitis caused by NTM in PubMed, Embase, and Ichushi databases up to August 2022. A total of 335 cases (64.1%, male; mean age, 53.4 years; mean dialysis duration, 25.4 months) were analyzed. The most common causative agent of infection was Mycobacterium abscessus (40.1%), followed by Mycobacterium fortuitum (24.8%) and Mycobacterium chelonae (16.6%). With respect to diagnosis, 42.9%, 28.1%, and 29.0% of cases were diagnosed as PD catheter-related infection only, peritonitis only, and both, respectively. The initial cultures were positive for NTM only, positive for any other bacteria, and negative for NTM only in 56.5%, 19.8%, and 23.7% of cases, respectively. Ultimately, more than 80% of cases were treated with multiple antibiotics. PD catheter removal was performed in 55.4% of patients with PD catheter-related infections only and 85.5% of those with PD peritonitis. PD continuation or resumption was possible in 62.2% and 16.0% of patients, respectively. In conclusion, our findings indicate that it is advisable to perform acid-fast bacilli stain and culture in order to promptly identify NTM. PD catheter removal may be an essential management strategy during the early stages of NTM infection.

Mycobacterium chelonae peritonitis in peritoneal dialysis. Literature review

Non-tuberculous mycobacteria are a rare but serious cause of peritoneal dialysis-related peritonitis. There are no clear guidelines for treating non-tuberculous mycobacteria peritoneal dialysis-associated infections. It has been recommended that at least two antibiotics be given for a prolonged period and peritoneal catheter should be removed. This paper describes the clinical course and treatment of a patient with M. chelonae peritoneal dialysis-related peritonitis and reviews the previously published cases.

Mycobacterium chelonae hand infection following ferret bite

We present a case of hand infection caused by Mycobacterium chelonae. The patient was a 58-year-old woman with Type II diabetes mellitus and stage 4 chronic kidney disease. The infection occurred following a ferret bite and had not responded to oral antibiotics in the primary care setting. She developed signs of pyogenic flexor tenosynovitis of the index and middle fingers of her left hand. Laboratory parameters showed high C-reactive protein, raised erythrocyte sedimentation rate and leucocytosis. Ultrasound imaging confirmed the clinical diagnosis. Plain radiographs showed no osseous involvement. The infection was treated with surgical debridement and broad spectrum parenteral antibiotics. The intra-operative tissue specimens were initially negative on aerobic and anaerobic cultures. Following transient improvement of her inflammatory parameters and clinical signs, she developed a recurrence with added features of osteomyelitis of the index and middle finger metacarpal heads on repeat radiographs. A revision surgical debridement of the flexor tenosynovitis and osteomyelitis with specific long-term antibiotic cover has led to resolution of the infection. Extended cultures of the tissue specimens at the regional laboratory confirmed the causative organism to be M. chelonae. To our knowledge, this is the first reported case of M. chelonae infection resulting from a ferret bite. This case reminds us of the need for a high index of suspicion for infection with uncommon pathogens following animal bites, especially in patients with altered immune status.

Peritoneal dialysis-associated nontuberculous mycobacterium peritonitis: a systematic review of reported cases

BACKGROUND

Peritonitis caused by nontuberculous mycobacterium (NTM) is an important complication in peritoneal dialysis (PD) patients.

METHODS

Cases of PD complicated by NTM peritonitis reported in the English language literature were identified in the PubMed database. The characteristics of these cases were reviewed.

RESULTS

In 41 articles, we identified 57 cases of PD-associated NTM peritonitis in patients ranging from 5 to 82 years. The prevalent clinical findings of these cases were fever, abdominal pain, cloudy fluid and an elevated leukocyte count in peritoneal fluid. These findings were non-specific and could not be differentiated from symptoms caused by Mycobacterium tuberculosis or other bacteria. The majority of these cases received empirical antibacterial therapy before diagnosis of NTM peritonitis. Isolates in more than half of the peritonitis cases were the rapidly growing Mycobacterium, Mycobacterium fortuitum (38.6%) and Mycobacterium chelonae (14.0%). In most cases, PD catheters were removed and experience with non-removal was limited.

CONCLUSION

Diagnosis of NTM infection should be considered in PD patients with peritonitis that are culture negative or refractory to empirical antibiotic therapy.