Peritonitis in CAPD patients—do not always use antibiotics!

(Section Editor: K. Kühn)

Der-Cherng Tarng, Tzen Wen Chen and Chin-Huang Chen

Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taiwan

Keywords: continuous ambulatory peritoneal dialysis; peritoneal eosinophilia

Case

A 71-year-old Chinese man presented in November 1995 with end-stage renal disease. He started on haemodialysis at an outpatient dialysis facility and then changed to CAPD 1 year later due to repeated occlusion of arteriovenous fistulae. Treatment was uneventful until three episodes of bacterial peritonitis developed from September to December 1998. At each episode, peritoneal effluent showed an increased leukocyte count with neutrophil predominance. The patient responded well each time to 2 weeks of antibiotics by intraperitoneal (i.p.) administration according to the susceptibility test of peritoneal effluent cultures. Unfortunately, abdominal pain and cloudy ascites occurred on 27 February 1999. Peritoneal effluent analysis showed leukocytes of 340/µl with 50% neutrophils, 17% lymphocytes, and 14% eosinophils. Empirical antibiotics with cefazolin plus tobramycin were administered i.p. However, cloudy ascites persisted and follow-up analysis of peritoneal effluent showed leukocytes of 140/µl with 29% neutrophils, 1% lymphocytes, and 65% eosinophils. Effluent cultures for bacteria and fungi were negative and antibiotics were used for 4 weeks until leukocytes of peritoneal effluent decreased to 43/µl. Three days after discontinuation of antibiotics, severe abdominal pain with cloudy ascites recurred. Peritoneal effluent disclosed white cells of 230/µl with 2% neutrophils, 7% lymphocytes, and 80% eosinophils (Figure 1Go), with Grams' stain negativity. The same IP antibiotics were used and the patient was referred to our institution in April 1999.



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Fig. 1. Increased leukocyte count with eosinophil predominance in peritoneal effluent (Wright's stain, 100x). Abbreviations, E, esinophil; Lym, lymphocyte; N, neutrophil.

 
Physical examination revealed a temperature of 37.2°C, blood pressure 113/55 mmHg, hypoactive bowel sounds, diffuse abdominal tenderness, and mild lower extremity oedema. Complete blood count showed leukocytes of 7100/µl with 64% neutrophils, and total eosinophils of 1000/µl in peripheral blood. Plasma IgE was 21 IU/ml, C-reactive protein 42 mg/l, and serum albumin 30 g/l. There were no parasites or ova on stool examination. Repeated effluent cultures were all negative for bacteria and fungi. Effluent eosinophils fluctuated, but were elevated persistently above 10% (Figure 2Go). Because eosinophilic peritoneal serositis was suspected, we ceased antibiotics and administered 10 mg of loratadine (ClaritynTM) per day orally. The initial response was favourable, and effluent eosinophils fell below 100/µl, in parallel with a decline of eosinophils to 10%. Later, 10 mg of prednisolone per day was given orally because of a flare-up of effluent eosinophils, progression of hypoalbuminaemia, and lower extremity oedema. Six days after steroid treatment, the peritoneal effluent became clear and leukocyte count was only of 1/µl. Follow-up blood eosinophils were 70/µl and plasma IgE <10 IU/ml. Eight weeks later, serum albumin increased from 30 to 41 g/l. When last seen in June 1999, the patient was doing well and had made a full recovery.



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Fig. 2. (a) Percent eosinophils, and (b) eosinophil counts in peritoneal effluent dialysate during eosinophilic peritoneal serositis. Day 1 is on 27 February 1999. Abbreviations, CEF+TOB, cefazolin plus tobramycin; CLA, clarityn; PRE, prednisolone.

 

Comments

Peritoneal eosinophilia is usually benign and self-limited in CAPD patients, but it becomes protracted in few cases complicated with fungal infection [1,2]. After exclusion of an infectious process, this entity is termed ‘eosinophilic peritoneal serositis’, characterized by allergic reaction and non-organismal inflammation [3].

Peritoneal eosinophilia is arbitrarily defined as an absolute eosinophil count of >100/µl [4] or eosinophils >10% of total effluent leukocytes in case of the eosinophil number >40/µl [5]. However, Chan et al. [4] declared that peritoneal eosinophilia should not be considered in patients even with eosinophils more than 15% of peritoneal fluid sediments, especially when total leukocyte count is below 250/µl. In our patient, the diagnosis was overlooked because of the antibiotics used as the first-line treatment for CAPD patients with evidence of peritonitis, and further impeded in the presence of effluent eosinophil count less than 100/µl. Following a series of peritoneal effluent analyses (Figure 2), eosinophils of >10% preceded the elevation of eosinophil count >100/µl for 3–4 weeks. Therefore we stress the point that an increase in percentage of eosinophils (>10%) in peritoneal effluent is a sensitive marker for early diagnosis of peritoneal eosinophilia and probably best reflects the allergic inflammatory state.

Peritoneal eosinophilia has been hypothesized as an allergic reaction. The offending agents included dialysate additives, air or blood introduced at the time of surgery, constituents in the peritoneal dialysis (PD) catheter, leaching of sterilants or plasticizers from the dialysis bag or tubing, or even mechanical trauma from too large a volume of exchange fluid or from catheter insertion. Accordingly, eosinophilic peritoneal serositis usually appears within 6 months after the start of peritoneal dialysis [4]. Our case had received CAPD treatment for more than 2 years and had been exposed to none of these offending factors recently. When faced with peritoneal eosinophilia, one should further differentiate eosinophilic peritoneal serositis from eosinophilic peritonitis complicated by fungal infection [1,2]. However, repeated effluent cultures for fungi were negative in our patient. Some investigators have proposed peritoneal eosinophilia as a reaction, to confer some immunity against peritonitis [6]. This might be a mechanistic explanation for our case, with evidence of blood eosinophilia and increased plasma IgE, following repeated bacterial peritonitis in the preceding 6 months.

Peritoneal eosinophilia is usually benign and self-limited. It deserves clinical observation without the necessity of antibiotic administration. Based on the allergic mechanism, oral antihistamine is advocated to achieve a sustained resolution in some cases [7]. The oral or i.p. administration of steroid has only been suggested for severe abdominal pain, for hypoalbuminaemia, or to maintain patency of the catheter if PD effluent is markedly turbid [4,8]. The response to loratadine was favourable initially but failed a week later in our patient. Oral prednisolone was added to loratadine on the 8th day of treatment because of progressive hypoalbuminaemia and lower extremity oedema. The combination therapy produced a dramatic improvement and sustained recovery, which corroborated the findings of Thakur et al. [8].

Teaching points

Notes

Supported by an educational grant from

Fresenius Medical Care

Correspondence and offprint requests to: Dr Der-Cherng Tarng MD, Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei 112, Taiwan. Back

References

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  4. Chan MK, Chow L, Lam SS, Jones B. Peritoneal eosinophilia in patients on continuous ambulatory peritoneal dialysis: a prospective study. Am J Kidney Dis1988; 11: 180–183[ISI][Medline]
  5. Chandran PK, Humayun HM, Daugirdas JT, Nawab ZM, Gandhi VC, Ing TS. Blood eosinophilia in patients undergoing maintenance peritoneal dialysis. Arch Intern Med1985; 145: 114–116[Abstract]
  6. Piraino BM, Silver MR, Dominguez JH, Puschett JB. Peritoneal eosinophils during intermittent peritoneal dialysis. Am J Nephrol1984; 4: 152–157[ISI][Medline]
  7. Tang S, Lo CJ, Lo WK, Chan TM. Resolution of eosinophilic peritonitis with Ketotifen. Am J Kidney Dis1997; 30: 433–436[ISI][Medline]
  8. Thakur SS, Unikowsky B, Prichard S. Eosinophilic peritonitis in CAPD: treatment with prednisone and diphenhydramine. Perit Dial Int1997; 17: 402–403[ISI][Medline]




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