PDI
MARCH 2015 - VOL. 35, NO. 2
Diagnostic Dilemma of Ultrafiltration Failure in a Continuous Ambulatory Peritoneal Dialysis Patient A 42-year-old male with chronic kidney disease (CKD), stage 5 on continuous ambulatory peritoneal dialysis (CAPD) using a swan-neck double-cuff Tenckhoff catheter presented with abdominal pain, vomiting, nausea and reduced appetite for 1 month, along with a poor dialysate outflow and ultrafiltration failure (< 400mL/day) for 20 days. As stated by the patient, dialysate effluent was clear. Abdominal examination was unremarkable. After a 6-hour dwell, the dialysate showed a leucocyte count of 0.17 x 109/L (170 cells) with 0.75 (75%) neutrophils and 0.24 (24%) lymphocytes, Gram stain negative, acid-fast bacilli (AFB) smear negative and no growth on L owenstein and Jensen culture medium. The Mantoux test done was unremarkable. Blood urea nitrogen was 12 mmol/L (33 mg/dL), serum creatinine 954 μmol/L (10.8 mg/dL), hemoglobin (Hb) 88 g/L (8.8 g/dL), erythrocyte sedimentation rate (ESR) 140 mm/hr, serum albumin 24 g/L(2.4 g/dL), electrolytes were normal. As the outflow was slow, an erect X-ray of the abdomen showed migration of the catheter (Figure 1), and a laproscopic examination showed intraperitoneal catheter with fibrinous exudates and adhesions (Figure 2), which were released. A peritoneal biopsy was done that showed granuloma with Langhans’ type giant cell suggestive of tuberculosis (Figure 3), and the biopsy specimen stained with Ziehl Neelsen stain showed acid-fast tubercle bacillus (Figure 4). A computed tomography (CT) of the chest showed left basal pulmonary scarring, small calcified right apical nodule, and calcified mediastinal nodules suggestive of pulmonary tuberculosis sequelae. The patient was initiated on rifampicin 450 mg OD, pyrazinamide 750 mg BID, ciprofloxacin 500 mg BID, isoniazid 150 mg OD, along
Figure 1 — Upward migration of the catheter (arrow).
SHORT REPORTS
with vitamin B6. Dialysate flow and ultrafiltration improved 7 days after starting the medication and the dialysate cell count returned to normal. DISCUSSION
In developing countries, when patients on CAPD show signs or symptoms of peritoneal inflammation, with a routine microbiology test showing negative results, a laproscopic examination with peritoneal biopsy is superior for diagnosing mycobacterial peritonitis, as illustrated in our patient. Institution of appropriate treatment improved ultrafiltration within a period of 7 days without the need for catheter removal.
Figure 2 — Intraperitoneal catheter with fibrinous exudates and adhesions.
Figure 3 — Granuloma with Langhans’ type giant cell (arrow).
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233
MARCH 2015 - VOL. 35, NO. 2 PDI
SHORT REPORTS
Pseudoporphyria in a Peritoneal Dialysis Patient Cutaneous changes can be observed in patients with endstage renal disease (ESRD). The most common findings are half-and-half nails, pruritus, xerosis, and cutaneous hyperpigmentation. Pseudoporphyria is a rare disease resembling porphyria cutanea tarda both clinically and pathologically (1). Factors involved in the etiology of pseudoporphyria include ultraviolet exposure, hemodialysis, and use of non-steroidal anti-inflammatory drugs, antibiotics, and diuretics (2). Although pseudoporphyria is seen in 13% of hemodialysis patients, it is rare in peritoneal dialysis (PD) patients (3). Here, we present a PD patient who developed pseudoporphyria after sun exposure. CASE DESCRIPTION
Figure 4 — Biopsy specimen stained with Ziehl Neelsen stain, with acid-fast tubercle bacillus (arrow). DISCLOSURES
The authors have no financial conflicts of interest to declare. Anand Yuvaraj1 Priyanka Joseph Koshy2 Anusha Rohit3 P Nagarajan4 Sanjeev Nair1 Lakshmi Revathi1 Georgi Abraham1* Department of Nephrology1 Department of Pathology2 Department of Microbiology3 Department of Surgery4 Madras Medical Mission, Chennai *email: [email protected] REFERENCES 1. Georgi A, Milly M, Lena S, Aparajitha S, Uma S, Soundarajan P. Tuberculous peritonitis in a cohort of continuous ambulatory peritoneal dialysis patients. Perit Dial Int 2001; 21(3):S202–4. 2. Gautam G, Milly M, Georgi A. Tuberculous peritonitis, poor ultrafiltration, and hypotension in a patient on continuous ambulatory peritoneal dialysis. Indian J Perit Dial 2010; 18:32–6. doi: 10.3747/pdi.2014.00086
234
A 71-year-old female presented with erythema and bullous lesions on both arms and hands that had not responded to self-administered topical steroids. She had been on PD for 10 years because of chronic glomerulonephritis. Her medications included amlodipine, sevelamer, calcitriol, atorvastatin, folic acid, and erythropoietin. She stated that she had had intense sun exposure before developing the skin changes. She denied taking any other medication. Physical examination revealed erythema, blisters, and crusted lesions on the dorsal aspects of the hands and forearms. The laboratory findings are presented in Table 1. Based on the history of sun exposure and characteristic skin lesions, a dermatologist diagnosed pseudoporphyria. The patient refused a skin biopsy. Oral N-acetyl cysteine (NAC) treatment was initiated. After 3 weeks, the skin lesions had resolved completely (Figure 1). TABLE 1 Patient Laboratory Results
Laboratory test
Result
Blood urea nitrogen 73 mg/dL Creatinine 8.7 mg/dL Sodium 137 mEq/L Potassium 4.1 mEq/L Total protein 6 g/dL Albumin 3.9 g/dL Calcium 10.7 mg/L Phosphorus 3.6 mg/dL White blood cells 9,100/μL Hemoglobin 13.9 g/dL Hematocrit 44% Platelets 241,000/μL Parathyroid hormone 402 pg/L Alanine aminotransferase 27 mEq/L Aspartate transaminase 22 mEq/L Ferritin 252 mg/dL C-reactive protein 3.7 mg/L
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]
MARCH 2015 - VOL. 35, NO. 2
Diagnostic Dilemma of Ultrafiltration Failure in a Continuous Ambulatory Peritoneal Dialysis Patient A 42-year-old male with chronic kidney disease (CKD), stage 5 on continuous ambulatory peritoneal dialysis (CAPD) using a swan-neck double-cuff Tenckhoff catheter presented with abdominal pain, vomiting, nausea and reduced appetite for 1 month, along with a poor dialysate outflow and ultrafiltration failure (< 400mL/day) for 20 days. As stated by the patient, dialysate effluent was clear. Abdominal examination was unremarkable. After a 6-hour dwell, the dialysate showed a leucocyte count of 0.17 x 109/L (170 cells) with 0.75 (75%) neutrophils and 0.24 (24%) lymphocytes, Gram stain negative, acid-fast bacilli (AFB) smear negative and no growth on L owenstein and Jensen culture medium. The Mantoux test done was unremarkable. Blood urea nitrogen was 12 mmol/L (33 mg/dL), serum creatinine 954 μmol/L (10.8 mg/dL), hemoglobin (Hb) 88 g/L (8.8 g/dL), erythrocyte sedimentation rate (ESR) 140 mm/hr, serum albumin 24 g/L(2.4 g/dL), electrolytes were normal. As the outflow was slow, an erect X-ray of the abdomen showed migration of the catheter (Figure 1), and a laproscopic examination showed intraperitoneal catheter with fibrinous exudates and adhesions (Figure 2), which were released. A peritoneal biopsy was done that showed granuloma with Langhans’ type giant cell suggestive of tuberculosis (Figure 3), and the biopsy specimen stained with Ziehl Neelsen stain showed acid-fast tubercle bacillus (Figure 4). A computed tomography (CT) of the chest showed left basal pulmonary scarring, small calcified right apical nodule, and calcified mediastinal nodules suggestive of pulmonary tuberculosis sequelae. The patient was initiated on rifampicin 450 mg OD, pyrazinamide 750 mg BID, ciprofloxacin 500 mg BID, isoniazid 150 mg OD, along
Figure 1 — Upward migration of the catheter (arrow).
SHORT REPORTS
with vitamin B6. Dialysate flow and ultrafiltration improved 7 days after starting the medication and the dialysate cell count returned to normal. DISCUSSION
In developing countries, when patients on CAPD show signs or symptoms of peritoneal inflammation, with a routine microbiology test showing negative results, a laproscopic examination with peritoneal biopsy is superior for diagnosing mycobacterial peritonitis, as illustrated in our patient. Institution of appropriate treatment improved ultrafiltration within a period of 7 days without the need for catheter removal.
Figure 2 — Intraperitoneal catheter with fibrinous exudates and adhesions.
Figure 3 — Granuloma with Langhans’ type giant cell (arrow).
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]
233
MARCH 2015 - VOL. 35, NO. 2 PDI
SHORT REPORTS
Pseudoporphyria in a Peritoneal Dialysis Patient Cutaneous changes can be observed in patients with endstage renal disease (ESRD). The most common findings are half-and-half nails, pruritus, xerosis, and cutaneous hyperpigmentation. Pseudoporphyria is a rare disease resembling porphyria cutanea tarda both clinically and pathologically (1). Factors involved in the etiology of pseudoporphyria include ultraviolet exposure, hemodialysis, and use of non-steroidal anti-inflammatory drugs, antibiotics, and diuretics (2). Although pseudoporphyria is seen in 13% of hemodialysis patients, it is rare in peritoneal dialysis (PD) patients (3). Here, we present a PD patient who developed pseudoporphyria after sun exposure. CASE DESCRIPTION
Figure 4 — Biopsy specimen stained with Ziehl Neelsen stain, with acid-fast tubercle bacillus (arrow). DISCLOSURES
The authors have no financial conflicts of interest to declare. Anand Yuvaraj1 Priyanka Joseph Koshy2 Anusha Rohit3 P Nagarajan4 Sanjeev Nair1 Lakshmi Revathi1 Georgi Abraham1* Department of Nephrology1 Department of Pathology2 Department of Microbiology3 Department of Surgery4 Madras Medical Mission, Chennai *email: [email protected] REFERENCES 1. Georgi A, Milly M, Lena S, Aparajitha S, Uma S, Soundarajan P. Tuberculous peritonitis in a cohort of continuous ambulatory peritoneal dialysis patients. Perit Dial Int 2001; 21(3):S202–4. 2. Gautam G, Milly M, Georgi A. Tuberculous peritonitis, poor ultrafiltration, and hypotension in a patient on continuous ambulatory peritoneal dialysis. Indian J Perit Dial 2010; 18:32–6. doi: 10.3747/pdi.2014.00086
234
A 71-year-old female presented with erythema and bullous lesions on both arms and hands that had not responded to self-administered topical steroids. She had been on PD for 10 years because of chronic glomerulonephritis. Her medications included amlodipine, sevelamer, calcitriol, atorvastatin, folic acid, and erythropoietin. She stated that she had had intense sun exposure before developing the skin changes. She denied taking any other medication. Physical examination revealed erythema, blisters, and crusted lesions on the dorsal aspects of the hands and forearms. The laboratory findings are presented in Table 1. Based on the history of sun exposure and characteristic skin lesions, a dermatologist diagnosed pseudoporphyria. The patient refused a skin biopsy. Oral N-acetyl cysteine (NAC) treatment was initiated. After 3 weeks, the skin lesions had resolved completely (Figure 1). TABLE 1 Patient Laboratory Results
Laboratory test
Result
Blood urea nitrogen 73 mg/dL Creatinine 8.7 mg/dL Sodium 137 mEq/L Potassium 4.1 mEq/L Total protein 6 g/dL Albumin 3.9 g/dL Calcium 10.7 mg/L Phosphorus 3.6 mg/dL White blood cells 9,100/μL Hemoglobin 13.9 g/dL Hematocrit 44% Platelets 241,000/μL Parathyroid hormone 402 pg/L Alanine aminotransferase 27 mEq/L Aspartate transaminase 22 mEq/L Ferritin 252 mg/dL C-reactive protein 3.7 mg/L
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]
