Extrapulmonary tuberculous infection manifested as peritoneal fluid eosinophilia in a continuous ambulatory peritoneal dialysis patient

Sun-Chieh Hsu, Rong-Ru Lan, Chin-Chung Tseng, Ching-Te Lai and Jeng-Jong Huang

Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, ROC

Sir,

Peritoneal fluid eosinophilia is a common event in peritoneal dialysis (PD) patients, especially during the first 3 months after initiation of PD therapy [1]. The mechanism for eosinophil infiltration into the peritoneal cavity is still unclear [13]. Herewith we present a uraemic patient on continuous ambulatory peritoneal dialysis (CAPD) with peritoneal fluid eosinophilia resulting from tuberculous lymphadenitis-related peripheral blood eosinophilia.

Case.

A 66-year-old female with a 6-year history of chronic renal failure due to tubulointerstitial nephritis reached end-stage renal disease in July 1998. She had hypertension which had been treated for 20 years and denied any systemic diseases or atopic disorders. CAPD therapy was chosen and implantation of a Swan-neck Missouri peritoneal catheter on July 8, 1998 was without complications. The pre-operative laboratory data showed: blood urea nitrogen 62 mg/dl; serum creatinine 7.3 mg/dl; creatinine clearance 8 ml/min; white blood cells 6700/mm3 with eosinophils 13%, neutrophils 63% and lymphocytes 18%; haemoglobin 8.2 g/dl; and platelets 173000/mm3. Thoracic radiographs revealed normal lung parenchyma. Stool analysis for parasitic ova was negative. The serum IgE level was within normal range. The physical examination was unremarkable.

Turbid dialysate effluent without any abdominal discomfort or fever developed in August 1998, soon after initiation of CAPD therapy. The dialysate effluent revealed white blood cells (1160/mm3) with eosinophilia (84%), and negative staining for micro-organisms including mycobacteria. Culture for micro-organisms yielded no growth. Since no definite infectious focus was found and the peritoneal fluid eosinophilia appeared upon starting CAPD therapy, we considered it to be a result of mechanical irritation and only further observation was undertaken.

Peritoneal fluid eosinophilia (54–85%) and peripheral eosinophilia (7–12%) persisted during the following 3 months, and a bone marrow study revealed only reactive eosinophilia. Progressive enlargement of bilateral neck masses (1–3 cm), and generalized malaise developed in October 1998. Computed tomography revealed multiple lymphadenopathies with significant central necrosis on both sides of the neck. Biopsy from the above lesions showed pus-like material with positive culture of unidentified non-fermentative Gram-negative bacilli, but no evidence of malignancy or granulomatous disease. After 3 weeks of treatment with piperacillin and gentamicin which were chosen according to the above sensitivity test, some resolution of neck lymphadenopathy was noted. However, the peripheral and peritoneal fluid eosinophilia persisted. CAPD therapy was stopped in November 1998 and replaced by thrice weekly haemodialysis. Two weeks later, the eosinophilia did not improve. A repeat biopsy of neck lymph nodes showed caseating necrosis with Langerhans' giant cell formation, and was negative for acid-fast stain and TB culture. In addition, detection of TB, using the polymerase chain reaction (PCR) technique, was negative for the dialysate effluent, urine, and sputum. Extrapulmonary (neck) TB lymphadenitis was diagnosed. Anti-TB chemotherapy consisting of isoniazid, rifampicin, ethambutol, and pyrazinamide was prescribed, and this led to a successful regression of the neck lymphadenitis. Her peripheral and peritoneal fluid eosinophilia also disappeared about 2 weeks later.

Discussion.

Peritoneal fluid eosinophilia or eosinophilic peritonitis is defined by the presence of >100 eosinophils/ mm3 in the peritoneal effluent or as an eosinophil count >10% of the total nonerythrocyte count [13]. The peritoneal fluid eosinophilia is a self-limiting and sterile process, without significant functional disturbance of the peritoneum [3]. Concomitant peripheral blood eosinophilia may also be present in over 50% of cases, but tends to mild [1,4]. The role and mechanism for peritoneal fluid eosinophilia are unclear. Mechanical or chemical irritant, hypersensitivity reaction, and adverse cytokine actions appear to contribute to eosinophil infiltration into the peritoneal cavity [13].

Uraemic patients are immuno-compromised and have a greater risk of developing TB from reactivation of silent disease [57]. Because of the significantly diminished immunocompetence associated with renal failure, the diagnosis of TB in uraemic patients is usually made in the first year after initiation of dialysis therapy [5,6]. A relatively high incidence of extrapulmonary involvement of TB, especially in lymph nodes [57] has been reported for uraemic patients. The clinical course and presentation are non-specific and often mimic that of underlying chronic renal failure. In addition, a positive skin test, acid-fast stain, or culture for TB are rarely found [5], making the diagnosis difficult. In some cases, the diagnosis can only be confirmed by a successful anti-TB therapeutic trial [5].

Our patient had mild peripheral eosinophilia before CAPD therapy, which may be the result of early, occult tuberculous lymphadenitis [8]. After initiation of CAPD, concomitant mild peripheral eosinophilia and severe peritoneal fluid eosinophilia persisted over 5 months, even after withdrawal of CAPD. The eosinophilia subsided after 2 weeks of anti-TB treatment. The only explanation for the above event was that the peritoneal fluid eosinophilia resulted from tuberculous lymphadenitis-related peripheral eosinophilia, but not vice versa. To our knowledge, this is the first reported case of TB-related peritoneal fluid eosinophilia.

In conclusion, in the early stage of initiation of dialysis therapy (usually within the first year), a high index of suspicion for an aggressive evaluation of TB are necessary if uraemic patients present with an unusual and unexplained clinical course. With early diagnosis and adequate treatment, the outcome of uraemia-related TB is positive [57]. However, the emergence of multiple drug-resistant TB due to insufficient treatment stemming from patient non-compliance and the high relapse rate of TB associated with short-term therapy, supports the use of prolonged treatment with a combination of multiple drugs for at least 6 months and patient education.

References

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  3. Ejaz AA, Fitzpatrick PM, Durkin AJ et al. Pathophysiology of peritoneal fluid eosinophilia in peritoneal dialysis patients. Nephron 1999; 81: 125–130[ISI][Medline]
  4. Chandran PK, Humayun HM, Dangirdas JT et al. Blood eosinophilia in patients undergoing maintenance peritoneal dialysis. Arch Intern Med 1985; 145: 114–116[Abstract]
  5. Belcon MC, Smith EKM, Kahana LM et al. Tuberculosis in dialysis patients. Clin Nephrol 1982; 17: 14–18[ISI][Medline]
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  8. Flores M, Merino-Angulce J, Tanago JG et al. Late generalized tuberculosis and eosinophilia. Arch Intern Med 1983; 143: 182[ISI][Medline]




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