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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 3  |  Page : 428-430
Brucella Peritonitis in a Patient on Peritoneal Dialysis


Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia

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   Abstract 

Brucellosis is endemic in Saudi Arabia. Brucella peritonitis is an uncommon clinical condition. We herewith report a 67-year-old man with chronic renal failure on continuous ambulatory peritoneal dialysis (CAPD) for four months, who developed chronic brucella peritonitis. Peritoneal fluid grew brucella species with positive brucella serology.

Keywords: Brucellosis, Peritonitis, Peritoneal Dialysis

How to cite this article:
Alothman A, Al Khurmi A, Al Sadoon S, AlHejaili F. Brucella Peritonitis in a Patient on Peritoneal Dialysis. Saudi J Kidney Dis Transpl 2008;19:428-30

How to cite this URL:
Alothman A, Al Khurmi A, Al Sadoon S, AlHejaili F. Brucella Peritonitis in a Patient on Peritoneal Dialysis. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2019 Aug 21];19:428-30. Available from: http://www.sjkdt.org/text.asp?2008/19/3/428/40504

   Introduction Top


Infection with the  Brucella More Details species is a systemic disease.  Brucellosis More Details is a zoonotic disease and remains endemic worldwide. [1],[2],[3] The clinical presentation of brucellosis can be polymorphic, which can cause a delay in making the correct diagnosis. [4] The mode of transmission of brucella organisms to humans is usually by direct contact with contaminated animals, ingestion of infec­ted dairy products and inhalation of infectious aerosols. [1],[2]

The clinical manifestations of brucellosis are variable; however, it was found that brucella peritonitis is a rare entity, parti­cularly in the Arabian peninsula. [5],[6],[7],[8],[9] The presence of a foreign body within the peritoneal cavity has been considered a risk factor to develop bacterial peritonitis, including infection with the brucella species. [17],[18]

Saudi Arabia is known to be endemic for brucellosis with the reported incidence in 2002 being 21 cases per 100,000 per year, which had actually dropped from 86 cases per 100,000 per year during early 1990. [9],[10] We report a case of brucella peritonitis in a patient on continuous ambulatory peri­toneal dialysis (CAPD); to the best of our knowledge, this appears to be the third such case in medical literature.


   Case Report Top


A 67-year-old man with end-stage renal disease (ESRD) on CAPD for four months presented with change of peritoneal fluid color, associated with abdominal pain and increased lower limb edema of one weeks' duration. There was a history of raw milk ingestion. There was no history of chest symptoms, fever or rigors. Past medical history was positive for hypertension and benign prostatic hypertrophy.

On physical examination, the patient was afebrile with normal vital signs. Chest and cardiovascular examination was normal. Abdominal examination revealed diffuse mild tenderness with clean CAPD catheter exit-site. There was bilateral lower limb edema.

Laboratory tests showed white blood cell (WBC) count of 8.1 x 10 9 cells/L, hemo­globin of 82 g/L and platelet count of 137,000/mm 3 . The serum creatinine was 293 µmol/L, blood urea was 12 mmol/L, alanine transaminase was 13 IU/L and electrolytes were normal. The erythrocyte sedimentation rate (ESR) was 63 mm/hr.

Analysis of the peritoneal fluid showed cloudy appearance, WBC count was 3356 cells/mm 3 with 8% lymphocytes and 85% neutrophils; the red blood cell count was 4 cells/mm 3 . Gram's stain did not show any organisms.

The patient was admitted to the hospital with a diagnosis of bacterial peritonitis and was started on cefazolin 1.0g given intra­peritoneally once daily. The patient im­proved clinically and peritoneal fluid ana­lysis repeated on the fourth day of admi­ssion showed clear appearance, WBC count of 11 cells/mm 3 , including 62% lympho­cytes and 12% neutrophils.

The patient was discharged and re­viewed after two weeks in the clinic at which time he was asymptomatic. Peritoneal fluid culture grew brucella species on day six after culture. Serology titer for  Brucella melitensis Scientific Name Search  was 1:2560, and for Brucella abortus, it was 1:640.

The patient was then started on doxy­cycline 100 mg and rifampicin 600 mg given orally once daily; the two drugs were given for a total duration of two months after presentation. Serology for Brucella melitensis was 1:5120, and for Brucella abortus, it was 1:2560. The peri­toneal dialysis catheter was removed and patient was shifted to hemodialysis. The patient was maintained on doxycylcine and rifampin for the next 12 weeks. Bru­cella serology at this point of time was 1:2560 for Brucella melitensis and 1:1280 for Brucella abortus. The patient remained asymptomatic and treat-ment was stopped. One-year later, brucella serology was 1:1280 for Brucella melitensis and 1:320 for Brucella abortus.


   Discussion Top


Brucella peritonitis appears to be an un­common disease, even in places where brucellosis is endemic. [3],[4],[5],[6],[9],[10],[11] In one study, generalized brucellosis was found in 96.2%, pneumonia in 1.3%, epididymo-orchitis in 1.3%, abortion in 0.6%, and threatened abortion in 0.6%. [6] It appears that seeding of brucella organisms to the peritoneal tissue is a very rare occurrence. [5]

A review of the medical literature re­vealed that most of the patients with bru­cella peritonitis were reported from Turkey. [3],[5],[7],[12],[13],[14] It is likely that this is due a high degree of awareness of brucellosis in Tur­key. Patients with brucella peritonitis had certain predisposing factors like chronic liver disease, [3],[9],[12],[13],[14] presence of ventriculo­peritoneal shunts, [15][,16] presence of CAPD catheter. [17],[18] or some unknown risks fac­tors. [7],[11],[19] Our patient developed chronic brucella peritonitis unlike the patient re­ported by Taskapan et al. [17] The risk factor was the presence of peritoneal dialysis catheter, and its removal helped in eradication of brucella organisms.

We recommend that patients on CAPD should have the peritoneal dialysis cathe­ter removed once the diagnosis of brucella peritonitis is made. Also, such patients should be on anti-brucella medication for 6-8 weeks.

 
   References Top

1.Young EJ. An overview of human brucellosis. Clin Infect Dis 1995;21 (2):283-9.  Back to cited text no. 1    
2.Corbel MJ. Brucellosis: An Overview. Emerg Infect Dis 1997;3(2):213-21.  Back to cited text no. 2    
3.Gursoy S, Baskol M, Ozbakir O, Guven K, Patirotilu T, Yucesoy M. Spontaneous bacterial peritonitis due to Brucella infection. Turk J Gastroenterol 2003;14 (2):145-7.  Back to cited text no. 3    
4.Al-Aska AK. Gastrointestinal manifes­tations of brucellosis in Saudi Arabian patients. Trop Gastroenterol 1989;10(4): 217-9.  Back to cited text no. 4    
5.Kantarceken B, Harputluoglu MM, Bayindir Y, Bayraktar MR, Aladall M, Hilmioglu F. Spontaneous bacterial peri­tonitis due to Brucella melitensis in a cirrhotic patient. Turk J Gastroenterol 2005;16(1):38-40.  Back to cited text no. 5    
6.Fallatah SM, Oduloju AJ, Al-Dusari SN, Fakunle YM. Human brucellosis in Northern Saudi Arabia. Saudi Med J 2005;26(10):1562-6.  Back to cited text no. 6    
7.Hatipoglu CA, Yetkin A, Ertem GT, Tulek N. Unusual Clinical presentations of brucellosis. Scand J Infect Dis 2004; 36(9):694-7.  Back to cited text no. 7    
8.Al Faraj S. Acute abdomen as atypical presentation of brucellosis: report of two cases and review of literature. J R Soc Med 1995;88(2):91-2.  Back to cited text no. 8    
9.Halim MA, Ayub A, Abdulkareem A, Ellis ME, al-Gazlan S. Brucella peritonitis. J Infect 1993;27(2):169-72.  Back to cited text no. 9    
10.Statistical report. Available from: http://www.moh.gov.sa/statistics/sb. 2002.  Back to cited text no. 10    
11.Akritidis N, Pappas G. Ascites caused by Brucellosis: A report of two cases. Scand J Gastroenterol 2001;36(1):110-2.  Back to cited text no. 11    
12.Erbay A, Bodur H. Akinci E, Colpan A, Cevik MA. Spontaneous bacterial peri­tonitis due to Brucella melitensis. Scand J Infect Dis 2003;35(3):196-7.  Back to cited text no. 12    
13.Gencer S, Ozer S. Spontaneous bacterial peritonitis caused by Brucella melitensis. Scand J Infect Dis 2003;35(5):341-3.  Back to cited text no. 13    
14.Doganay M, Aygen B, Inan M, Ozbakir O. Brucella peritonitis in cirrhotic patients with ascites. Eur J Med 1993;2(7):441-2.  Back to cited text no. 14    
15.Anderson H, Mortensen A. Unrecognized Neurobrucellosis giving rise to Brucella melitensis peritonitis via a venticulo­peritoneal shunt. Eur J Clin Microbiol Infect Dis 1992;11(10):953-4.  Back to cited text no. 15    
16.Locutura J, Lorenzo JF, Mijan A, Galdos­Barroso M, Saez-Royuela F. Non simul­taenous Brucella peritonitis and menin­gitis in a patient with a ventriculo peritoneal shunt. Eur J Clin Microbiol Infect Dis 1998;17(5):361-2.  Back to cited text no. 16    
17.Taskapan H, Oymak O, Sumerkan B, Tokgoz B, Utas C. Brucella peritonitis in a patient on continuous ambulatory peritoneal dialysis with acute brucellosis. Nephron 2002;91(1):156-8.  Back to cited text no. 17    
18.Ozisik L, Akman B, Huddan B, et al. Isolated Brucella peritonitis in a CAPD patient. Am J Kidney Dis 2006;47(5):e65-6.  Back to cited text no. 18    
19.Diab SM, Araj GF, al-Asfour AJ, al­Yusuf AR. Brucellosis: Atypical pre­sentation with peritonitis and meningitis. Trop Geogr Med 1989;41:160-3.  Back to cited text no. 19  [PUBMED]  

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Correspondence Address:
Adel Alothman
Department of Medicine, Mail Code 1443, King Abdulaziz Medical City, Riyadh
Saudi Arabia
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PMID: 18445904

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    Abstract
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