Peritoneal dialysis-related peritonitis with bacteraemia due to Erysipelothrix rhusiopathiae

Sir,

Case. A 49-year-old bricklayer with end-stage renal failure secondary to adult polycystic kidney disease had been on continuous ambulatory peritoneal dialysis (CAPD) for 1 year. He presented with a 1-day history of abdominal pain, rigors and cloudy bags. Multiple excoriations were present on his hands. The CAPD fluid had a white cell count (WCC) of >100 x 106/l with no red cells. The fluid was inoculated into an Oxoid bottle (Oxoid signal blood culture system, Oxoid Ltd, Basingstoke, UK). Filtration was not performed as only 20 ml was received. The peripheral WCC was 12.7 x 109/l. Intraperitoneal vancomycin and gentamicin were commenced. His abdominal pain failed to settle, and by day 4 signs of severe peritonitis were present. Blood cultures were taken and repeat CAPD fluid had a WCC of >100 x 106/l. Laparotomy was performed with removal of the Tenchkoff catheter and peritoneal lavage. Purulent free fluid was present throughout the abdominal cavity. Intravenous ciprofloxacin 200 mg bd was started according to local policy to cover possible Pseudomonas peritonitis or other bowel-related organisms.

On day 5, a Gram-positive rod was grown from the first CAPD fluid and identified as Erysipelothrix rhusiopathiae, using the API Coryne (BioMerieux UK Ltd, Basingstoke, UK). It was resistant to vancomycin and gentamicin but sensitive to ciprofloxacin, penicillin, erythromycin and cefuroxime. The same organism was identified subsequently from blood cultures, although the second CAPD fluid and an intraoperative swab taken from the CAPD tunnel were both culture negative. Symptoms resolved, a vascath was inserted for haemodialysis, and he was discharged following 12 days of ciprofloxacin. He remained on haemodialysis until his death from unrelated causes 8 months later.

Comment. Erysipelothrix rhusiopathiae is a Gram-positive rod which may be confused with Lactobacillus, Corynebacterium or Enterococcus spp on the basis of morphology and biochemical tests [1]. It has a wide geographical distribution and has been reported from a variety of animals as a commensal or pathogen [1]. It causes severe disease in domestic pigs, poultry and sheep. Colonization has been reported in fish, shellfish and birds. The organism can survive in soil for several months [1].

Infection in humans usually follows cutaneous inoculation so is often related to occupational exposure, i.e. butchers, fishmongers and veterinarians [1]. There are three main clinical syndromes. The most common is erysipeloid, a painful localized violaceous skin lesion. Less commonly described are a more severe, diffuse cutaneous form and also a bacteraemic illness usually associated with endocarditis [1]. Most cases of bacteraemia without endocarditis have occurred in immunocompromised hosts [2].

Most strains of E.rhusiopathiae are sensitive to penicillins, cephalosporins, imipenem, clindamycin, erythromycin and ciprofloxacin. Penicillin is the antibiotic of choice. Most are resistant to vancomycin, aminoglycosides, teicoplanin and trimethoprim-sulfamethoxazole. The glycopeptide resistance is of particular note as vancomycin is often used as empiric treatment of Gram-positive bacteraemia or endocarditis, and intraperitoneal vancomycin and gentamicin is a common first-line treatment for CAPD peritonitis [3]. Most Gram-positive rods are vancomycin sensitive. Only one reported case of bacteraemia or endocarditis has been treated successfully with ciprofloxacin [4]. Our patient had improved by the time sensitivities were available, so ciprofloxacin was continued instead of switching to penicillin.

This is the second reported case of CAPD peritonitis caused by this organism, and the first European case. The first case occurred in a rancher who cut his hand on a barbed wire fence around an animal enclosure 2 weeks before admission [5]. He became pyrexial with a skin lesion on his hand. Initial treatment was with intravenous gentamicin and intraperitoneal amikacin, changed to intravenous penicillin following isolation of the organism from CAPD fluid. No organisms were seen on the Gram stain. In contrast to our case, blood cultures were sterile and the patient responded to medical treatment.

CAPD peritonitis may occur by several routes. The most common is thought to be intraluminal and is the major route for skin and environmental organisms. The extraluminal (i.e. tunnel migration) route may complicate exit site infections. The transluminal route (i.e. migration across the bowel wall) involves bowel flora. Infection by the haematogenous route may complicate bacteraemia. The intraluminal or haematogenous route seems most likely in this case. No direct animal exposure was documented, but inoculation from a contaminated environmental source may have occurred through excoriated hands.

This case demonstrates the importance of identifying and determining the sensitivity of all isolates from CAPD fluids. Ciprofloxacin may be used to treat E.rhusiopathiae bacteraemia in patients with a severe penicillin allergy.

Conflict of interest statement. None declared.

Susan C. Hardman1, Susan J. Carr2 and R. Andrew Swann1

1Department of Microbiology 2Department of Nephrology University Hospitals of Leicester Leicester, UK Email: susanhardman{at}hotmail.com

References

  1. Mandell GL, Bennett JE, Dolin R, eds. Erysipelothrix rhusiopathiae. In: Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases, 5th edn. Churchill Livingstone, Edinburgh; 2000: 2226–2227
  2. Ognibene FP, Cunnion RE, Gill V et al. Erysipelothrix rhusiopathiae bacteraemia presenting as septic shock. Am J Med 1985; 78: 861–864[ISI][Medline]
  3. Keane WF, Everett ED, Golper TA et al. Peritoneal dialysis-related peritonitis treatment recommendations: 1993 update. Perit Dial Int 1993; 13: 14–28[ISI][Medline]
  4. MacGowan AP, Reeves DS, Wright C et al. Tricuspid valve infective endocarditis and pulmonary sepsis due to Erysipelothrix rhusiopathiae successfully treated with high doses of ciprofloxacin but complicated by gynaecomastia. J Infect 1991; 22: 100–101[ISI][Medline]
  5. Carlini ME, Clarridge JE, Rodriguez-Barradas MC. Erysipelothrix rhusiopathiae peritonitis in a patient on continuous ambulatory peritoneal dialysis. Infect Dis Clin Pract 1998; 7: 419–421[ISI]




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