| Abstract|| |
We report a four-year old Saudi boy who was on continuous ambulatory peritoneal dialysis using a Y-connector system. He developed peritonitis without associated exit-site infection. Xanthomonas maltophilia was grown from the dialysis effluent. The organism was sensitive to netalmycin, tetracycline and co-trimoxazole. The patient responded to treatment with co-trimoxazole given for a total of ten days. However, he presented with a second episode of peritonitis and the same organism was grown again from the dialysis effluent. Due to intractable infection, the PD catheter had to be removed during the second episode of peritonitis.
Keywords: Peritonitis, CAPD, Xanthomonas maltophilia.
|How to cite this article:|
Singh R G, Soyannwo M, Ronald R, Khan N I, Usha, Gugunani H. Xanthomonas Maltophilia Peritonitis in a CAPD Patient. Saudi J Kidney Dis Transpl 1997;8:145-7
|How to cite this URL:|
Singh R G, Soyannwo M, Ronald R, Khan N I, Usha, Gugunani H. Xanthomonas Maltophilia Peritonitis in a CAPD Patient. Saudi J Kidney Dis Transpl [serial online] 1997 [cited 2019 Aug 24];8:145-7. Available from: http://www.sjkdt.org/text.asp?1997/8/2/145/39388
| Introduction|| |
Peritonitis is one of the commonest complications in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). It accounts for considerable morbidity and also necessitates, in some patients, for the treatment modality to be changed to hemodialysis. The incidence of peritonitis has decreased in recent years to one episode every two years  . The most common pathogens implicated are gram positive organisms (75%). Occasionally, gram negative organisms, mycobacteria, anaerobes and fungi have been reported as etiological agents of peritonitis ,,, . We report here an unusual case of peritonitis due to Xanthomonas maltophilia in a CAPD patient.
| Case Report|| |
A four-year old Saudi boy presented with end-stage renal failure to the King Fahd Hospital, Buraidah, Saudi Arabia. He was put on CAPD with a standard Y-connection system after training his mother regarding the procedure. He was prescribed four exchanges of 500 ml per day. During the subsequent 13-month period, the patient had 15 episodes of peritonitis for which he was hospitalized for a period of 2 to 25 days per episode. During each hospitalization renal chemistry, complete hematological profile, urinalysis, peritoneal dialysis (PD) effluent cytology as well as culture and exit- site swab for culture was done in addition to relevant radiological examinations. The PD effluent yielded coagulase negative Staphylococcus once, Escherichia More Details coli twice, and on ten occasions, the cultures were sterile.
About 15 months after commencement of CAPD, the patient was brought to the emergency department of the hospital, with complaints of turbid peritoneal effluent, poor drainage and fever of three days duration. Physical examination revealed a toxic looking boy with a temperature of 38.4°C, pulse rate of 120/min. and blood pressure of 150/90 mm Hg. The jugular venous pressure was not raised and cardiovascular examination was normal except for tachycardia. Examination of the chest revealed a few bilateral basal crepitations. The abdomen was distended, tender on palpation with a bulge at the umbilical region due to hernia. The exit-site appeared normal. A diagnosis of peritonitis with umbilical hernia was made. Hematological examination revealed raised ESR and an elevated neutrophil count with low hemoglobin. The cell count of the PD effluent was 1700/cu mm. Blood cultures were repeatedly sterile while the PD effluent yielded an unusual organism on two occasions which was identified as Xanthomonas maltophilia by API 20E system. The organism was sensitive to tetracycline, cotrimoxazole and netalmicin as tested by Bauer and Kerly method employing Mailer Hunton Agar and Britania sensitivity discs. Prior to culture, the patient was treated with ceftazidime, metronidazole and vancomycin administered intra-peritoneally. After obtaining the culture results, the patient was put on co-trimoxazole (80 mg trimethoprim, 400 mg sulphamethoxazole) half tablet twice a day orally for 10 days. He became afebrile after two days of therapy and the PD effluent cell count decreased to 5/cu mm.
About one month after discharge, the patient presented with similar complaints and turbid peritoneal effluent of three days duration. In addition, chest examination showed evidence of pneumonitis. Blood cultures were sterile while the PD effluent grew Xanthomonas maltophilia on three consecutive occasions. The isolate was again sensitive to tetracycline, co-trimoxazole and netalmicin. In view of the intractable infection, the CAPD catheter was removed after administration of two oral doses of cotrimoxazole and the patient was put on hemodialysis by placing a subclavian venous catheter. He became asymptomatic after two days of therapy with co-trimoxazole and cefaloxine which was continued for a total of 10 days.
| Discussion|| |
Xanthomonas maltophilia is an ubiquitous free living organism. It can infect plants and can colonize several body sites of hospitalized patients causing a variety of infections such as pneumonia, bacteremia, endocarditis, urinary tract infection and cholangitis , . Infection in immunocompromised hosts, such as those with malignancy on immunosuppression, can be severely life threatening.
To the best of our knowledge, our report constitutes the first record of peritonitis due to Xanthomonas maltophilia. Dapena, et al reported on 13 episodes of Xanthomonas related exit-site infection in their patients over a nine-year period. One of these episodes resulted in peritonitis  . Our patient, being a case of end-stage renal failure on CAPD, was in an immunocompromised state and was thus predisposed to infection. Regrettably, we could not eliminate or establish the source of infection and the catheter exit-site was unaffected. It is possible that he acquired the organism from infected plant material at his residence which was located in a rural, agricultural area.
The isolates of Xanthomonas maltophilia are characteristically resistant to several antimicrobial agents including aminoglycosides and Imipenem , . The organism has two inducible broad spectrum B-lactamases and low outer membrane permeability; hence it rapidly develops resistance to B-lactam agents  . It is known to be sensitive to cotrimoxazole, tetracycline and netalmycin as was the case with our isolate , . Treatment with co-trimoxazole on both occasions for 10 days duration was expectedly successful.
Thus, our report serves to emphasize that in immunocompromised states or in intractable situations while managing CAPD peritonitis, one should keep options open and look for unusual causative organisms as illustrated in the present case.
| Acknowledgement|| |
We are thankful to our Hospital Director and Laboratory staff of the Department of Microbiology of King Fahd Specialist Hospital, Buraydah for their support in this study.
| References|| |
|1.||Khanna R, Nolph KD. CAPD-An overview. Saudi J Kidney Dis Transplant I994;5:23-7. |
|2.||Morrison AJ Jr, Hoffman KK, Wenzal RP. Associated mortality and clinical characteristics of nosocomial pseudomonas maltophilia in a university hospital. J Clin Microbiol 1986;24:52-5. |
|3.||Wens R, Dratwa M, Potvliege C, Hansen W, Tielemans C, Collart F. Campylobacter fetus peritonitis followed by septicemia in a patient on continuous ambulatory peritoneal dialysis. J Infect 1985;10:249-51. [PUBMED] |
|4.||Muder RR, Yu VL, Dummer JS, Vinson C, Lumish RM. Infections caused by pseudomonas maltophilia. Expanding clinical spectrum. Arch Intern Med 1987;147:1672-74. |
|5.||Dapena F, Selgas R, Garcia Perea A, et al. Clinical significance of exit-site infections due to xanthomonas in CAPD patients: a comparison with pseudomonas infection. Nephrol Dia! Transplant 1994;9(12):1774-7. |
|6.||Elting LS, Bodey GP. Septicemia due to xanthomonas species and non-aeruginosa pseudomonas species: increasing incidence of catheter-related infections. Medicine Baltimore 1990;69:296-306. [PUBMED] |
|7.||Schoch PE, Cunaha BA. Pseudomonas maltophilia Infect Control 1987;8:169-72. |
|8.||Mett H, Rosta S, Schacher B, Frei R. Outer membrane permeability and beta-lactamase content in pseudomonas maltophilia clinical isolates and laboratory mutants. Rev Infect Dis 1988;10:765-9. [PUBMED] |
R G Singh
Professor and Head of Nephrology, Dialysis and Transplantation Unit, University Hospital, Banaras Hindu University, Varanasi - 221005, India