Peritoneal Dialysis International, Vol. 34, pp. 469–472 Printed in Canada. All rights reserved.
0896-8608/14 $3.00 + .00 Copyright © 2014 International Society for Peritoneal Dialysis
Correspondence Staphylococcus lentus Peritonitis: A Case Report KEY WORDS: Peritonitis; zoonosis.
DISCLOSURES
The authors have no financial conflicts of interest to declare. Maite Rivera* Martha Diaz Dominguez Nuria Rodriguez Mendiola Gloria Ruiz Roso Carlos Quereda
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]
469
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Editor: Peritonitis due to animal bacteria (zoonosis) is an infrequent complication in peritoneal dialysis (PD). We present here a case of peritonitis due to Staphylococcus lentus (S. lentus), a coagulase-negative bacterium of animal origin that rarely affects humans. A non-diabetic 55-year-old man treated with automated PD for 31 months was admitted with abdominal pain and cloudy effluent. Exit site appeared normal. Leukocyte count of the effluent showed 7,640/mm3 with 88.5% polymorphonuclear cells. Gram stain of a sample of turbid peritoneal effluent was negative. Cultures of exit site and effluent were taken. Empiric treatment with intraperitoneal vancomycin and Tobramycin was instituted. Abdominal pain rapidly improved and leukocyte count was lower than 100/mm3 after 4 days of treatment. A Staphylococcus lentus grew on cultures of exit site and abdominal effluent which was sensitive to vancomycin, cloxacillin and Tobramycin. The patient received 15 days of vancomycin (3 doses) with total resolution of peritonitis and without relapse. Tobramycin was stopped on day 5. Since S. lentus is usually an animal pathogen and the patient lives in an urban area, we asked the patient if he had had contact with animals. He reported that he had a horse and rides twice a week. Zoonosis in patients on PD represents 0.03 – 0.54% of total peritonitis episodes (1,2). It has been isolated in less than 15 different microorganisms causing peritonitis of animal origin. The most reported bacterium is Pasteurella multocida, which is mainly transmitted by cats. Since antibiotic sensibility and culture growth rate are quite different in bacteria from animals with respect to common bacteria producing infectious peritonitis, an adequate treatment can be delayed. Zoonosis in PD raises questions concerning the desirability of PD patients having pets or coming into contact with farm animals (2).
S. lentus is a coagulase-negative staphylococcus that belongs to the Staphylococcus sciuri group (S. sciuri, S. lentus, and S. vitulinus). Those staphylococci are known animal pathogens and they have been isolated from rodents, chickens, mammals and in farm soil and water (3). S. sciuri may colonize humans and produce serious infections, such as endocarditis septic shock, urinary tract infection, wound infections, endophthalmitis, and pelvic inflammatory disease (4). A case of peritonitis due to S. sciuri has been reported (5) but, to our knowledge, a case of S. lentus in a PD patient has not yet been published. Unlike S. sciuri, S. lentus lacks the Mec A gene, making the S. lentus more susceptible to antibiotics than other members of the S. sciuri group, which are oxacillinresistant staphylococci, and frequently resistant to other antibiotics (6). The treatment of choice for S. sciuri infections is vancomycin although b-lactam antibiotics are also effective. Due to the diversity of infective agents transmitted by animals, it is impossible to create general antibiotic guidelines for all of them. Positive culture of peritoneal effluent remains the most important factor to determine antibiotherapy. Therefore, we want to emphasize the importance of antibiograms even in coagulase-negative bacteria. Our patient had frequent contact with horses. We can speculate that the S. lentus could have come from the horse through skin contact, perhaps due to inadequate hand washing after riding and before doing his peritoneal exchanges. This case illustrates the need to identify all coagulasenegative staphylococci since they are sometimes a contaminant in asymptomatic patients.
june 2014 - Vol. 34, No. 4
CORRESPONDENCE
Hospital Ramon Y Cajal – Nephrology Carretera De Colmenar Km 9,100 Madrid, Spain *email: [email protected] REFERENCES
doi:10.3747/pdi.2012.00303
Abdominal Pseudocyst Development in a Peritoneal Dialysis Patient With a Ventriculoperitoneal Shunt: An Indication for Switch to Hemodialysis? Editor: A ventriculoperitonal shunt (VPS) is one of the therapeutic approaches in patients with hydrocephalus. Patients may rarely require a VPS and renal replacement therapy concurrently (1). Although some concerns may arise about the safety of peritoneal dialysis (PD), it is not accepted as a contraindication in patients with a VPS (2,3). An abdominal pseudocyst is a rarely observed but potentially serious complication of a VPS. The exact pathogenesis is unknown but thought to be secondary to infection or inflammatory response (4–6). We report a PD patient with a VPS complicated by an abdominal pseudocyst which was not previously reported in PD patients. A 22-year old female patient was admitted to the hospital with nausea, vomiting and abdominal distension. Her past medical history revealed that a VPS had been 470
implanted when she was 2 months old; she had been followed without any complication such as central nervous system infection or shunt malfunction afterwards and no shunt revision had been required. She also had chronic kidney disease secondary to a neurogenic bladder and started PD at the age of 17. This modality had probably been chosen because of the absence of optimum vascular access due to severe physical developmental retardation. She had been under PD treatment for 5 years. She had 3 peritonitis episodes that were treated with intravenous and intraperitoneal antibiotics. None of the peritonitis episodes were complicated with central nervous system infection. The patient had been switched to hemodialysis 3 months before presentation because of multiple peritonitis and poor drainage, which was probably related to post-peritonitic adhesions. On current admission, the patient’s general condition was good and she was afebrile. Severe physical developmental delay was evident. There were severe abdominal distention and decreased bowel sounds without abdominal defense or rebound. The patient’s blood urea was 111 mg/dL, creatinine 6.8 mg/dL, hemoglobin 8.6 g/dL, white blood cell 4300/mm³, albumin 2.9 g/dL and c-reactive protein 18.3 mg/L. Abdominal ultrasonography revealed massive intra-abdominal fluid with septations. Abdominal computerized tomography confirmed this lesion as an approximately 20 x 30 cm pseudocyst with internal septae and a thick wall (Figure 1). There were no white or red blood cells in the microscopic examination of the fluid and no pathogenic microorganism was grown in the fluid culture. The patient was treated with a drainage catheter and 5.5 liters of xanthocromatic fluid was drained. The patient was discharged from the hospital in an extremely good general condition. This patient with a VPS did not require shunt revision for 22 years. However, complications arose from an abdominal pseudocyst after initiation of PD, probably
Figure 1 — Abdominal computerized tomography imaging demonstrating a pseudocyst of approximately 20×30 cm with septae and a thick wall.
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]
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1. Broughton A, Verger C, Goffin E. Pets-related peritonitis in peritoneal dialysis: Companion animals or Trojan horses? Semin Dial 2010; 23:306–16. 2. Schiller B, Alcaraz M, Hadley K, Moran J. Peritonitis and zoonosis: your best friend sometimes isn’t! Perit Dial Int 2011; 31:127–30. 3. Stepanovic S, Dakic I, Morrison D, Hauschild T, Jezek P, Petrás P, et al. Identification and characterization of clinical isolates of members of the Staphylococcus sciuri group. J Clin Microbiol 2005; 43:956–8. 4. Daki´c I, Morrison D, Vukovi´c D, Savi´c B, Shittu A, Jezek P, et al. Isolation and molecular characterization of Staphylococcus sciuri in the hospital environment. J Clin Microbiol 2005; 43:2782–5. 5. Wallet F, Stuit L, Boulanger E, Roussel-Delvallez M, Dequiedt P, Courcol RJ. Peritonitis due to Staphylococcus sciuri in a patient on continuous ambulatory peritoneal dialysis. Scand J Infect Dis 2000; 32:697–8. 6. Stepanovic S, Jezek P, Dakic I, Vukovic D, Seifert L. Staphylococcus sciuri: an unusual cause of pelvic inflammatory disease. Int J STD AIDS 2005; 16:452–3.
PDI
0896-8608/14 $3.00 + .00 Copyright © 2014 International Society for Peritoneal Dialysis
Correspondence Staphylococcus lentus Peritonitis: A Case Report KEY WORDS: Peritonitis; zoonosis.
DISCLOSURES
The authors have no financial conflicts of interest to declare. Maite Rivera* Martha Diaz Dominguez Nuria Rodriguez Mendiola Gloria Ruiz Roso Carlos Quereda
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]
469
Downloaded from http://www.pdiconnect.com/ at WASHINGTON UNIVERSITY on November 18, 2015
Editor: Peritonitis due to animal bacteria (zoonosis) is an infrequent complication in peritoneal dialysis (PD). We present here a case of peritonitis due to Staphylococcus lentus (S. lentus), a coagulase-negative bacterium of animal origin that rarely affects humans. A non-diabetic 55-year-old man treated with automated PD for 31 months was admitted with abdominal pain and cloudy effluent. Exit site appeared normal. Leukocyte count of the effluent showed 7,640/mm3 with 88.5% polymorphonuclear cells. Gram stain of a sample of turbid peritoneal effluent was negative. Cultures of exit site and effluent were taken. Empiric treatment with intraperitoneal vancomycin and Tobramycin was instituted. Abdominal pain rapidly improved and leukocyte count was lower than 100/mm3 after 4 days of treatment. A Staphylococcus lentus grew on cultures of exit site and abdominal effluent which was sensitive to vancomycin, cloxacillin and Tobramycin. The patient received 15 days of vancomycin (3 doses) with total resolution of peritonitis and without relapse. Tobramycin was stopped on day 5. Since S. lentus is usually an animal pathogen and the patient lives in an urban area, we asked the patient if he had had contact with animals. He reported that he had a horse and rides twice a week. Zoonosis in patients on PD represents 0.03 – 0.54% of total peritonitis episodes (1,2). It has been isolated in less than 15 different microorganisms causing peritonitis of animal origin. The most reported bacterium is Pasteurella multocida, which is mainly transmitted by cats. Since antibiotic sensibility and culture growth rate are quite different in bacteria from animals with respect to common bacteria producing infectious peritonitis, an adequate treatment can be delayed. Zoonosis in PD raises questions concerning the desirability of PD patients having pets or coming into contact with farm animals (2).
S. lentus is a coagulase-negative staphylococcus that belongs to the Staphylococcus sciuri group (S. sciuri, S. lentus, and S. vitulinus). Those staphylococci are known animal pathogens and they have been isolated from rodents, chickens, mammals and in farm soil and water (3). S. sciuri may colonize humans and produce serious infections, such as endocarditis septic shock, urinary tract infection, wound infections, endophthalmitis, and pelvic inflammatory disease (4). A case of peritonitis due to S. sciuri has been reported (5) but, to our knowledge, a case of S. lentus in a PD patient has not yet been published. Unlike S. sciuri, S. lentus lacks the Mec A gene, making the S. lentus more susceptible to antibiotics than other members of the S. sciuri group, which are oxacillinresistant staphylococci, and frequently resistant to other antibiotics (6). The treatment of choice for S. sciuri infections is vancomycin although b-lactam antibiotics are also effective. Due to the diversity of infective agents transmitted by animals, it is impossible to create general antibiotic guidelines for all of them. Positive culture of peritoneal effluent remains the most important factor to determine antibiotherapy. Therefore, we want to emphasize the importance of antibiograms even in coagulase-negative bacteria. Our patient had frequent contact with horses. We can speculate that the S. lentus could have come from the horse through skin contact, perhaps due to inadequate hand washing after riding and before doing his peritoneal exchanges. This case illustrates the need to identify all coagulasenegative staphylococci since they are sometimes a contaminant in asymptomatic patients.
june 2014 - Vol. 34, No. 4
CORRESPONDENCE
Hospital Ramon Y Cajal – Nephrology Carretera De Colmenar Km 9,100 Madrid, Spain *email: [email protected] REFERENCES
doi:10.3747/pdi.2012.00303
Abdominal Pseudocyst Development in a Peritoneal Dialysis Patient With a Ventriculoperitoneal Shunt: An Indication for Switch to Hemodialysis? Editor: A ventriculoperitonal shunt (VPS) is one of the therapeutic approaches in patients with hydrocephalus. Patients may rarely require a VPS and renal replacement therapy concurrently (1). Although some concerns may arise about the safety of peritoneal dialysis (PD), it is not accepted as a contraindication in patients with a VPS (2,3). An abdominal pseudocyst is a rarely observed but potentially serious complication of a VPS. The exact pathogenesis is unknown but thought to be secondary to infection or inflammatory response (4–6). We report a PD patient with a VPS complicated by an abdominal pseudocyst which was not previously reported in PD patients. A 22-year old female patient was admitted to the hospital with nausea, vomiting and abdominal distension. Her past medical history revealed that a VPS had been 470
implanted when she was 2 months old; she had been followed without any complication such as central nervous system infection or shunt malfunction afterwards and no shunt revision had been required. She also had chronic kidney disease secondary to a neurogenic bladder and started PD at the age of 17. This modality had probably been chosen because of the absence of optimum vascular access due to severe physical developmental retardation. She had been under PD treatment for 5 years. She had 3 peritonitis episodes that were treated with intravenous and intraperitoneal antibiotics. None of the peritonitis episodes were complicated with central nervous system infection. The patient had been switched to hemodialysis 3 months before presentation because of multiple peritonitis and poor drainage, which was probably related to post-peritonitic adhesions. On current admission, the patient’s general condition was good and she was afebrile. Severe physical developmental delay was evident. There were severe abdominal distention and decreased bowel sounds without abdominal defense or rebound. The patient’s blood urea was 111 mg/dL, creatinine 6.8 mg/dL, hemoglobin 8.6 g/dL, white blood cell 4300/mm³, albumin 2.9 g/dL and c-reactive protein 18.3 mg/L. Abdominal ultrasonography revealed massive intra-abdominal fluid with septations. Abdominal computerized tomography confirmed this lesion as an approximately 20 x 30 cm pseudocyst with internal septae and a thick wall (Figure 1). There were no white or red blood cells in the microscopic examination of the fluid and no pathogenic microorganism was grown in the fluid culture. The patient was treated with a drainage catheter and 5.5 liters of xanthocromatic fluid was drained. The patient was discharged from the hospital in an extremely good general condition. This patient with a VPS did not require shunt revision for 22 years. However, complications arose from an abdominal pseudocyst after initiation of PD, probably
Figure 1 — Abdominal computerized tomography imaging demonstrating a pseudocyst of approximately 20×30 cm with septae and a thick wall.
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 WASHINGTON UNIVERSITY on November 18, 2015
1. Broughton A, Verger C, Goffin E. Pets-related peritonitis in peritoneal dialysis: Companion animals or Trojan horses? Semin Dial 2010; 23:306–16. 2. Schiller B, Alcaraz M, Hadley K, Moran J. Peritonitis and zoonosis: your best friend sometimes isn’t! Perit Dial Int 2011; 31:127–30. 3. Stepanovic S, Dakic I, Morrison D, Hauschild T, Jezek P, Petrás P, et al. Identification and characterization of clinical isolates of members of the Staphylococcus sciuri group. J Clin Microbiol 2005; 43:956–8. 4. Daki´c I, Morrison D, Vukovi´c D, Savi´c B, Shittu A, Jezek P, et al. Isolation and molecular characterization of Staphylococcus sciuri in the hospital environment. J Clin Microbiol 2005; 43:2782–5. 5. Wallet F, Stuit L, Boulanger E, Roussel-Delvallez M, Dequiedt P, Courcol RJ. Peritonitis due to Staphylococcus sciuri in a patient on continuous ambulatory peritoneal dialysis. Scand J Infect Dis 2000; 32:697–8. 6. Stepanovic S, Jezek P, Dakic I, Vukovic D, Seifert L. Staphylococcus sciuri: an unusual cause of pelvic inflammatory disease. Int J STD AIDS 2005; 16:452–3.
PDI
