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with kinking, which might have caused damage to the catheter at the start, with the damage being worsened during each dialysate exchange and the repeated migration with kinking. The eventual result was full fracture of catheter (Figure 3). We conclude that Tenckhoff catheter fracture is a rare cause of catheter malfunction, but that catheter fracture should be considered in the differential diagnosis of catheter malfunction. ACKNOWLEDGMENTS


The authors have no financial conflicts of interest. Y.C. Chang1,2 K.H. Lee1,2 T.H. Chen3 P.J. Tsai3 P.Y. Chen1,2 M.C. Guo1,2 S.A. Lin1,2 J.Y. Chen1,2 W.C. Yang1,2 Y.Y. Ng1,2*

An Unusual Case of Hemoperitoneum: Spontaneous Rectus Sheath Hematoma Editor: A 66-year-old woman on peritoneal dialysis (PD) was admitted to our nephrology unit because of acute abdominal pain located near the catheter exit site (left lower quadrant). The pain had started 1 hour before admission. No fever, diarrhea, or vomiting were reported. Clinical examination revealed increased tenderness in the left lower quadrant on palpation, blood pressure of 100/50 mmHg, and a heart rate of 110 bpm. No obvious abdominal swelling or mass was apparent. The first urgent exchange performed in the unit revealed hemoperitoneum. This patient had been on a continuous ambulatory PD schedule for 5 years. Her primary renal disease was glomerulonephritis attributable to systemic lupus erythematosus. The patient had experienced an upper respiratory viral infection 10 days earlier, and a persistent dry cough was evident thereafter. No trauma or malfunction of the catheter was reported. Routine medication included furosemide and a beta-blocker; no anticoagulant treatment had ever been administered. Because of increasing pain and hemodynamic instability, emergent non-contrast computed tomography imaging of the abdomen was performed, revealing a rectus sheath hematoma (Figure 1). Laboratory exams showed an important decline in hematocrit (to 24% from 34%). Platelet count, thrombin time, and partial throm-

Division of Nephrology1 Department of Medicine2 Department of Surgery3 Taipei Veterans General Hospital National Yang-Ming University School of Medicine Taipei, Taiwan *email: [email protected] REFERENCES 1. Closkey GM, Zappacosta AR. CAPD drainage failure due to Tenckhoff catheter fracture: a case report. Perit Dial Int 1992; 12:266–7. 2. Tsuchida K, Takemoto Y, Nakamura T, Yamagami S. Unexpected complication resulting from peritoneal dialysis catheter break. Perit Dial Int 1998; 18:444–5. 3. Zappacosta A, Perra S. Continuous ambulatory peritoneal dialysis. Philadelphia, PA: Lippincott; 1984: 110. doi:10.3747/pdi.2012.00239


Figure 1 — Rectus sheath hematoma (arrow) evident on computed tomography imaging.

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This study was supported by grants (NSC 96-2629-B-075-001, V101-C-186) from the National Science Council and by the Taipei Veterans General Hospital, Taiwan. We also thank Sandy Cho for her revision of the manuscript.



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*

An unusual case of hemoperitoneum: spontaneous rectus sheath hematoma.

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