PDI
january 2014 – Vol. 34, No. 1 correspondence
long intervals in the past, but corticosteroids are not associated with bleeding disorders. One common complication of chronic corticosteroid use is myopathy and skin thinning. Although the hematoma was close to the catheter, no trauma to the catheter was reported. That background, plus the increased abdominal strain caused by a tense cough, might explain the hematoma. DISCLOSURES
The authors have no financial conflicts of interest to declare.
Figure 2 — The growing ecchymosis on the patient’s abdomen.
boplastin time were within normal limits. Examination of the effluent showed no leukocytes. The patient was treated conservatively: Vital signs were closely monitored, and 2 transfusions and analgesics were given. Dialysate exchanges remained bloody during the following hours. The next day, an ecchymosis on the abdomen began to be obvious. During the subsequent days, exchanges became clearer, the ecchymosis grew greater (Figure 2), and the patient’s symptoms improved. Her vital signs were stable. On day 5 of hospitalization, the patient was mobilized and discharged. Peritoneal dialysis provides a window to the peritoneum. Hemoperitoneum is a well-recognized complication in PD. Menstruation, catheter-related malfunctions, and intra-abdominal pathology of solid organs and the gastrointestinal tract are the most common causes (1). Rectus sheath hematoma (RSH) is an uncommon condition in the general population, usually being a complication of abdominal trauma or surgery. Spontaneous RSH is often a complication of the increasing use of anticoagulant therapies combined with excessive strain on the abdominal muscles (2). In PD patients, RSH has only rarely been described as a complication of PD catheter insertion (3). Hemoperitoneum as first presentation of RSH in a prevalent PD patient has not yet been described in the literature. There were questions about the cause of the hematoma in our patient. She had never received antiplatelet or anticoagulant therapy. Clinically, systemic lupus erythematosus is associated with bleeding when the platelet count is less than 20 000/μL or when antibodies against factor VIII are apparent [in which case, partial thromboplastin time is increased (4)]. In our patient, platelet count and partial thromboplastin time were within normal limits. She had taken corticosteroids for
Department of Nephrology1 Department of Surgery2 Internal Medicine3 University of Ioannina Ioannina, Greece *email: [email protected] REFERENCES 1. Lew SQ. Hemoperitoneum: bloody peritoneal dialysate in ESRD patients receiving peritoneal dialysis. Perit Dial Int 2007; 27:226–33. 2. Salemis NS. Spontaneous rectus sheath hematoma presenting as acute surgical abdomen: an important differential in elderly coagulopathic patients. Geriatr Gerontol Int 2009; 9:200–2. 3. Jayawardene SA, Goldsmith DJ. Rectus sheath haematomata in patients with renal disease. Nephrol Dial Transplant 2002; 17:1832–5. 4. Lafferty TE, Smith JB, Schuster SJ, DeHoratius RJ. Treatment of acquired factor VIII inhibitor using intravenous immunoglobulin in two patients with systemic lupus erythematosus. Arthritis Rheum 1997; 40:775–8. doi:10.3747/pdi.2012.00178
A Rare Cause of Peritoneal Dialysis–Related Peritonitis: Achromobacter denitrificans Editor: Achromobacter denitrificans is a gram-negative bacterium formerly known as Alcaligenes denitrificans and only recently reclassified as Achromobacter (1). An aerobic,
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O. Balafa1 S. Koundouris1 M. Mitsis2 K.C. Siamopoulos3*
CORRESPONDENCE
january 2014 – Vol. 34, No. 1
136
DISCLOSURES
The authors have no financial conflicts of interest to declare. E. Cankaya1* M. Keles1 E. Gulcan1 A. Uyanik1 H. Uyanik2 Department of Nephrology1 Department of Microbiology2 Faculty of Medicine Ataturk University Erzurum, Turkey *email: [email protected] REFERENCES 1. Sgrelli A, Mencacci A, Fiorio M, Orlandi C, Baldelli F, De Socio GV. Achromobacter denitrificans renal abscess. New Microbiol 2012; 35:245–7. 2. Weitkamp JH, Tang YW, Haas DW, Midha NK, Crowe JE Jr. Recurrent Achromobacter xylosoxidans bacteremia associated with persistent lymph node infection in a patient with hyper-immunoglobulin M syndrome. Clin Infect Dis 2000; 31:1183–7. 3. Ahmed MS, Nistal C, Jayan R, Kuduvalli M, Anijeet HK. Achromobacter xylosoxidans, an emerging pathogen in catheter-related infection in dialysis population causing prosthetic valve endocarditis: a case report and review of literature. Clin Nephrol 2009; 71:350–4. 4. Appelbaum PC, Campbell DB. Pancreatic abscess associated with Achromobacter group Vd biovar 1. J Clin Microbiol 1980; 12:282–3. 5. Lucatelli JF, Cantarelli VV, Pıcoli SU. Conjunctivitis due to Achromobacter xylosoxidans: case report [Portuguese]. Arq Bras Oftalmol 2009; 72:261–3. 6. Morrison AJ Jr, Boyce K 4th. Peritonitis caused by Alcaligenes denitrificans subsp. xylosoxydans: case report and review of the literature. J Clin Microbiol 1986; 24:879–81. 7. Coenye T, Vancanneyt M, Cnockaert MC, Falsen E, Swings J, Vandamme P. Kerstersia gyiorum gen. nov., sp. nov., a novel Alcaligenes faecalis–like organism isolated from human clinical samples, and reclassification of Alcali genes denitrificans Rüger and Tan 1983 as Achromobacter denitrificans comb. nov. Int J Syst Evol Microbiol 2003; 53:1825–31. 8. Tsai MT, Yang WC, Lin CC. Continuous ambulatory peritoneal dialysis–related exit-site infections caused by Achromobacter denitrificans and A. xylosoxidans. Perit Dial Int 2012; 32:362–3.
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
Downloaded from http://www.pdiconnect.com/ at University of Auckland on June 29, 2015
non-fermenting, oxidase- and catalase-positive motile bacterium, A. denitrificans has been isolated in soil and water (2). This bacterium may be part of the normal flora of the ear and the gastrointestinal and respiratory tracts in some people. A. denitrificans rarely causes infection in humans. The case of peritonitis reported here is the first observed in a patient undergoing continuous ambulatory peritoneal dialysis (CAPD). The patient, a 60-year-old woman, had been undergoing CAPD for 6 years. She had a history of 3 peritonitis episodes, the last of which had occurred 2 years earlier. She was admitted to our clinic with complaints of abdominal pain, nausea, vomiting, and fever that had begun the preceding day. The catheter exit site and tunnel were normal. Effluent white blood cells were 1800/mm3, with a predominance of neutrophils. No micro-organisms could be identified in a gram-stain of the effluent. The patient was diagnosed with CAPD-related peritonitis and started empirically on vancomycin and ciprofloxacin after culture samples had been obtained. Growth of A. denitrificans was observed in the effluent culture. No micro-organism growth was observed in the blood cultures. The A. deni trificans was sensitive to ciprofloxacin. Vancomycin was discontinued. Effluent white blood cells rapidly declined to below 100/mm3, and the patient’s complaints fully resolved. Infections with A. denitrificans are observed only rarely. In infected patients, A. denitrificans has been isolated in blood, peritoneal and pleural fluid, urine, and sweat. The risk factors identified for Achromo bacter infections include immune insufficiency, HIV infection, malignancy, cystic fibrosis, and hospitalization (2,3). None of those risk factors was present in our patient. A. denitrificans can cause endocarditis in natural and prosthesis valves, pneum onia, meningitis, peritonitis, conjunctivitis, osteomyelitis, and intra-abdominal abscesses (1,4,5). To our knowledge, peritonitis caused by Al. denitrificans subspecies xylosoxidans was previously reported only in a case published by Morrison and Boyce in 1986 (6). However, their description of Al. denitrificans was the same as the description given by Coenye et al. for Al. xylosoxidans subspecies denitrificans (7). Exit-site infections in CAPD caused by A. denitrificans and A. xylosoxidans have been reported. However, only A. xylosoxidans has been reported as a cause of CAPDassociated peritonitis (8,9). To summarize, A. denitrificans is a rare cause of CAPD peritonitis. However, it can be successfully treated with antibiotic therapy and without removal of the peritoneal catheter.
PDI
PDI
january 2014 – Vol. 34, No. 1 correspondence
9. Ledger SG, Cordy P. Successful treatment of Alcaligenes xylosoxidans in automated peritoneal dialysis–related peritonitis. Perit Dial Int 2007; 27:596–8. doi:10.3747/pdi.2013.00063
Fidaxomicin for Clostridium difficile Colitis in a Peritoneal Dialysis Patient with Underlying Mitochondriopathy
CASE REPORT
In September 2012, a 49-year-old woman on PD was admitted for a first episode of peritonitis (Enterobacter cloacae). Her underlying renal disease was hereditary mitochondriopathy (3243A>G mutation of mitochondrial DNA). Initial treatment consisted of intraperitoneal vancomycin and ceftazidime per local protocol, with good recovery. Seven weeks later, this patient was readmitted with nausea and vomiting. She was febrile, but the effluent was clear. Inflammatory markers were significantly elevated. The same day, she developed profuse diarrhea, and C. difficile infection was diagnosed by a combined enzyme immunoassay for C. difficile glutamate dehydrogenase and C. difficile toxins A and B. Cultures for Campylobacter and Salmonella came back negative. The patient was placed on contact precautions, and metronidazole 500 mg 3 times daily was prescribed. Recovery was slow, and oral vancomycin 250 mg 4 times daily was added on day 11 because of persistent diarrhea. After a fortnight in hospital, the patient was discharged home. This patient re-presented 3 weeks later with profuse diarrhea. On examination, she appeared toxic, and laboratory results showed a severe inflammatory response (C-reactive protein peak: 224 mg/L). Recurrent disease was confirmed microbiologically. Oral vancomycin was recommenced, but did not lead to clinical improvement over the next 5 days. The patient ate little and had lost 8 kg in weight since her initial presentation in September. Because she was increasingly compromised by protracted illness and because her inflammatory markers continued to rise, fidaxomicin (200 mg twice daily) was added on day 6 of this admission. Diarrhea abated promptly, and
DISCUSSION
Fidaxomicin is a potent, albeit expensive, new treatment option for severe relapsing C. difficile colitis, with limited systemic absorption (2,3). No contraindications are listed in the prescribing information, and no dose adjustment based on renal function is recommended (3,4). To the best of our knowledge, this report is the first of successful fidaxomicin use in a PD patient. We are not aware of any data pertaining to drug levels in peritoneal dialysate and suggest that testing should be performed on a future occasion. The unusual underlying renal disease warrants emphasis. Mitochondrial disorders are associated with protean manifestations, including gastrointestinal complications ranging from reflux and constipation to frank pseudo-obstruction. Given this underlying intestinal dysmotility, an increased risk of PD-related peritonitis is conceivable in this population (5). Certain drugs—new systemic antibiotics among them—are known to trigger severe side effects in patients with mitochondriopathies (6). Compounds with minimal absorption such as fidaxomicin could represent a safer alternative under such circumstances. DISCLOSURES
The authors have no financial conflicts of interest to declare. M. Windpessl* M. Wallner Division of Nephrology Fourth Department of Medicine Klinikum Wels–Grieskirchen Wels, Austria *email: [email protected] REFERENCES 1. Wolfgram DF, Foster D, Astor BC, Chan MR. Development of Clostridium difficile colitis in peritoneal dialysis patients treated for peritonitis. Perit Dial Int 2012; 32:666–8. 2. Louie TJ, Miller MA, Mullane KM, Weiss K, Lentnek A, Golan
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
137
Downloaded from http://www.pdiconnect.com/ at University of Auckland on June 29, 2015
Editor: The interesting observations by Wolfgram and colleagues (1) prompted us to contribute our recent experi e nce with a peritoneal dialysis (PD) patient suffering from recurrent Clostridium difficile colitis.
C-reactive protein almost normalized over the next 4 days. The patient was allowed to go home with 7 more days of fidaxomicin. During 3 months of follow-up, she continued to make a good recovery from her prolonged and severe illness.
january 2014 – Vol. 34, No. 1 correspondence
long intervals in the past, but corticosteroids are not associated with bleeding disorders. One common complication of chronic corticosteroid use is myopathy and skin thinning. Although the hematoma was close to the catheter, no trauma to the catheter was reported. That background, plus the increased abdominal strain caused by a tense cough, might explain the hematoma. DISCLOSURES
The authors have no financial conflicts of interest to declare.
Figure 2 — The growing ecchymosis on the patient’s abdomen.
boplastin time were within normal limits. Examination of the effluent showed no leukocytes. The patient was treated conservatively: Vital signs were closely monitored, and 2 transfusions and analgesics were given. Dialysate exchanges remained bloody during the following hours. The next day, an ecchymosis on the abdomen began to be obvious. During the subsequent days, exchanges became clearer, the ecchymosis grew greater (Figure 2), and the patient’s symptoms improved. Her vital signs were stable. On day 5 of hospitalization, the patient was mobilized and discharged. Peritoneal dialysis provides a window to the peritoneum. Hemoperitoneum is a well-recognized complication in PD. Menstruation, catheter-related malfunctions, and intra-abdominal pathology of solid organs and the gastrointestinal tract are the most common causes (1). Rectus sheath hematoma (RSH) is an uncommon condition in the general population, usually being a complication of abdominal trauma or surgery. Spontaneous RSH is often a complication of the increasing use of anticoagulant therapies combined with excessive strain on the abdominal muscles (2). In PD patients, RSH has only rarely been described as a complication of PD catheter insertion (3). Hemoperitoneum as first presentation of RSH in a prevalent PD patient has not yet been described in the literature. There were questions about the cause of the hematoma in our patient. She had never received antiplatelet or anticoagulant therapy. Clinically, systemic lupus erythematosus is associated with bleeding when the platelet count is less than 20 000/μL or when antibodies against factor VIII are apparent [in which case, partial thromboplastin time is increased (4)]. In our patient, platelet count and partial thromboplastin time were within normal limits. She had taken corticosteroids for
Department of Nephrology1 Department of Surgery2 Internal Medicine3 University of Ioannina Ioannina, Greece *email: [email protected] REFERENCES 1. Lew SQ. Hemoperitoneum: bloody peritoneal dialysate in ESRD patients receiving peritoneal dialysis. Perit Dial Int 2007; 27:226–33. 2. Salemis NS. Spontaneous rectus sheath hematoma presenting as acute surgical abdomen: an important differential in elderly coagulopathic patients. Geriatr Gerontol Int 2009; 9:200–2. 3. Jayawardene SA, Goldsmith DJ. Rectus sheath haematomata in patients with renal disease. Nephrol Dial Transplant 2002; 17:1832–5. 4. Lafferty TE, Smith JB, Schuster SJ, DeHoratius RJ. Treatment of acquired factor VIII inhibitor using intravenous immunoglobulin in two patients with systemic lupus erythematosus. Arthritis Rheum 1997; 40:775–8. doi:10.3747/pdi.2012.00178
A Rare Cause of Peritoneal Dialysis–Related Peritonitis: Achromobacter denitrificans Editor: Achromobacter denitrificans is a gram-negative bacterium formerly known as Alcaligenes denitrificans and only recently reclassified as Achromobacter (1). An aerobic,
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
135
Downloaded from http://www.pdiconnect.com/ at University of Auckland on June 29, 2015
O. Balafa1 S. Koundouris1 M. Mitsis2 K.C. Siamopoulos3*
CORRESPONDENCE
january 2014 – Vol. 34, No. 1
136
DISCLOSURES
The authors have no financial conflicts of interest to declare. E. Cankaya1* M. Keles1 E. Gulcan1 A. Uyanik1 H. Uyanik2 Department of Nephrology1 Department of Microbiology2 Faculty of Medicine Ataturk University Erzurum, Turkey *email: [email protected] REFERENCES 1. Sgrelli A, Mencacci A, Fiorio M, Orlandi C, Baldelli F, De Socio GV. Achromobacter denitrificans renal abscess. New Microbiol 2012; 35:245–7. 2. Weitkamp JH, Tang YW, Haas DW, Midha NK, Crowe JE Jr. Recurrent Achromobacter xylosoxidans bacteremia associated with persistent lymph node infection in a patient with hyper-immunoglobulin M syndrome. Clin Infect Dis 2000; 31:1183–7. 3. Ahmed MS, Nistal C, Jayan R, Kuduvalli M, Anijeet HK. Achromobacter xylosoxidans, an emerging pathogen in catheter-related infection in dialysis population causing prosthetic valve endocarditis: a case report and review of literature. Clin Nephrol 2009; 71:350–4. 4. Appelbaum PC, Campbell DB. Pancreatic abscess associated with Achromobacter group Vd biovar 1. J Clin Microbiol 1980; 12:282–3. 5. Lucatelli JF, Cantarelli VV, Pıcoli SU. Conjunctivitis due to Achromobacter xylosoxidans: case report [Portuguese]. Arq Bras Oftalmol 2009; 72:261–3. 6. Morrison AJ Jr, Boyce K 4th. Peritonitis caused by Alcaligenes denitrificans subsp. xylosoxydans: case report and review of the literature. J Clin Microbiol 1986; 24:879–81. 7. Coenye T, Vancanneyt M, Cnockaert MC, Falsen E, Swings J, Vandamme P. Kerstersia gyiorum gen. nov., sp. nov., a novel Alcaligenes faecalis–like organism isolated from human clinical samples, and reclassification of Alcali genes denitrificans Rüger and Tan 1983 as Achromobacter denitrificans comb. nov. Int J Syst Evol Microbiol 2003; 53:1825–31. 8. Tsai MT, Yang WC, Lin CC. Continuous ambulatory peritoneal dialysis–related exit-site infections caused by Achromobacter denitrificans and A. xylosoxidans. Perit Dial Int 2012; 32:362–3.
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
Downloaded from http://www.pdiconnect.com/ at University of Auckland on June 29, 2015
non-fermenting, oxidase- and catalase-positive motile bacterium, A. denitrificans has been isolated in soil and water (2). This bacterium may be part of the normal flora of the ear and the gastrointestinal and respiratory tracts in some people. A. denitrificans rarely causes infection in humans. The case of peritonitis reported here is the first observed in a patient undergoing continuous ambulatory peritoneal dialysis (CAPD). The patient, a 60-year-old woman, had been undergoing CAPD for 6 years. She had a history of 3 peritonitis episodes, the last of which had occurred 2 years earlier. She was admitted to our clinic with complaints of abdominal pain, nausea, vomiting, and fever that had begun the preceding day. The catheter exit site and tunnel were normal. Effluent white blood cells were 1800/mm3, with a predominance of neutrophils. No micro-organisms could be identified in a gram-stain of the effluent. The patient was diagnosed with CAPD-related peritonitis and started empirically on vancomycin and ciprofloxacin after culture samples had been obtained. Growth of A. denitrificans was observed in the effluent culture. No micro-organism growth was observed in the blood cultures. The A. deni trificans was sensitive to ciprofloxacin. Vancomycin was discontinued. Effluent white blood cells rapidly declined to below 100/mm3, and the patient’s complaints fully resolved. Infections with A. denitrificans are observed only rarely. In infected patients, A. denitrificans has been isolated in blood, peritoneal and pleural fluid, urine, and sweat. The risk factors identified for Achromo bacter infections include immune insufficiency, HIV infection, malignancy, cystic fibrosis, and hospitalization (2,3). None of those risk factors was present in our patient. A. denitrificans can cause endocarditis in natural and prosthesis valves, pneum onia, meningitis, peritonitis, conjunctivitis, osteomyelitis, and intra-abdominal abscesses (1,4,5). To our knowledge, peritonitis caused by Al. denitrificans subspecies xylosoxidans was previously reported only in a case published by Morrison and Boyce in 1986 (6). However, their description of Al. denitrificans was the same as the description given by Coenye et al. for Al. xylosoxidans subspecies denitrificans (7). Exit-site infections in CAPD caused by A. denitrificans and A. xylosoxidans have been reported. However, only A. xylosoxidans has been reported as a cause of CAPDassociated peritonitis (8,9). To summarize, A. denitrificans is a rare cause of CAPD peritonitis. However, it can be successfully treated with antibiotic therapy and without removal of the peritoneal catheter.
PDI
PDI
january 2014 – Vol. 34, No. 1 correspondence
9. Ledger SG, Cordy P. Successful treatment of Alcaligenes xylosoxidans in automated peritoneal dialysis–related peritonitis. Perit Dial Int 2007; 27:596–8. doi:10.3747/pdi.2013.00063
Fidaxomicin for Clostridium difficile Colitis in a Peritoneal Dialysis Patient with Underlying Mitochondriopathy
CASE REPORT
In September 2012, a 49-year-old woman on PD was admitted for a first episode of peritonitis (Enterobacter cloacae). Her underlying renal disease was hereditary mitochondriopathy (3243A>G mutation of mitochondrial DNA). Initial treatment consisted of intraperitoneal vancomycin and ceftazidime per local protocol, with good recovery. Seven weeks later, this patient was readmitted with nausea and vomiting. She was febrile, but the effluent was clear. Inflammatory markers were significantly elevated. The same day, she developed profuse diarrhea, and C. difficile infection was diagnosed by a combined enzyme immunoassay for C. difficile glutamate dehydrogenase and C. difficile toxins A and B. Cultures for Campylobacter and Salmonella came back negative. The patient was placed on contact precautions, and metronidazole 500 mg 3 times daily was prescribed. Recovery was slow, and oral vancomycin 250 mg 4 times daily was added on day 11 because of persistent diarrhea. After a fortnight in hospital, the patient was discharged home. This patient re-presented 3 weeks later with profuse diarrhea. On examination, she appeared toxic, and laboratory results showed a severe inflammatory response (C-reactive protein peak: 224 mg/L). Recurrent disease was confirmed microbiologically. Oral vancomycin was recommenced, but did not lead to clinical improvement over the next 5 days. The patient ate little and had lost 8 kg in weight since her initial presentation in September. Because she was increasingly compromised by protracted illness and because her inflammatory markers continued to rise, fidaxomicin (200 mg twice daily) was added on day 6 of this admission. Diarrhea abated promptly, and
DISCUSSION
Fidaxomicin is a potent, albeit expensive, new treatment option for severe relapsing C. difficile colitis, with limited systemic absorption (2,3). No contraindications are listed in the prescribing information, and no dose adjustment based on renal function is recommended (3,4). To the best of our knowledge, this report is the first of successful fidaxomicin use in a PD patient. We are not aware of any data pertaining to drug levels in peritoneal dialysate and suggest that testing should be performed on a future occasion. The unusual underlying renal disease warrants emphasis. Mitochondrial disorders are associated with protean manifestations, including gastrointestinal complications ranging from reflux and constipation to frank pseudo-obstruction. Given this underlying intestinal dysmotility, an increased risk of PD-related peritonitis is conceivable in this population (5). Certain drugs—new systemic antibiotics among them—are known to trigger severe side effects in patients with mitochondriopathies (6). Compounds with minimal absorption such as fidaxomicin could represent a safer alternative under such circumstances. DISCLOSURES
The authors have no financial conflicts of interest to declare. M. Windpessl* M. Wallner Division of Nephrology Fourth Department of Medicine Klinikum Wels–Grieskirchen Wels, Austria *email: [email protected] REFERENCES 1. Wolfgram DF, Foster D, Astor BC, Chan MR. Development of Clostridium difficile colitis in peritoneal dialysis patients treated for peritonitis. Perit Dial Int 2012; 32:666–8. 2. Louie TJ, Miller MA, Mullane KM, Weiss K, Lentnek A, Golan
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
137
Downloaded from http://www.pdiconnect.com/ at University of Auckland on June 29, 2015
Editor: The interesting observations by Wolfgram and colleagues (1) prompted us to contribute our recent experi e nce with a peritoneal dialysis (PD) patient suffering from recurrent Clostridium difficile colitis.
C-reactive protein almost normalized over the next 4 days. The patient was allowed to go home with 7 more days of fidaxomicin. During 3 months of follow-up, she continued to make a good recovery from her prolonged and severe illness.
