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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2012  |  Volume : 23  |  Issue : 2  |  Page : 321-324
Peritonitis caused by Mycobacterium abscesses in patients on continuous ambulatory peritoneal dialysis


Division of Nephrology, Department of Medicine, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia

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Date of Web Publication28-Feb-2012
 

   Abstract 

Nontuberculous mycobacteria are an uncommon cause of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis. We report two cases of peritonitis caused by Mycobacterium abscesses from a single center, which were successfully treated. In endemic areas of tuberculosis, Zeil Neilsen staining should be part of the initial evaluation to allow early detection. Treatment requires removal of Tenckhoff catheter and second-line antibiotics until cultures become negative.

How to cite this article:
Siddiqi N, Sheikh I. Peritonitis caused by Mycobacterium abscesses in patients on continuous ambulatory peritoneal dialysis. Saudi J Kidney Dis Transpl 2012;23:321-4

How to cite this URL:
Siddiqi N, Sheikh I. Peritonitis caused by Mycobacterium abscesses in patients on continuous ambulatory peritoneal dialysis. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2014 Sep 2];23:321-4. Available from: http://www.sjkdt.org/text.asp?2012/23/2/321/93166

   Introduction Top


In patients undergoing continuous ambula­tory peritoneal dialysis (CAPD), peritonitis is a common complication usually with gram-positive bacteria. Peritonitis with Mycobac-terium tuberculosis (MTB) is well known, with higher rates reported from endemic areas. The incidence of MTB has been reported to be declining among patients with end-stage renal disease (ESRD) in Saudi Arabia. [1] However, the rate of infections with atypical myco-bacterium is not well quantified. Several cases of peritonitis due to nontuberculous mycobacteria (NTM) have been reported in patients undergoing CAPD.


   Case Report Top


Case l

A 60-year-old Saudi female on CAPD for five years had an accidental removal of her Tenck-hoff catheter which was replaced. Six weeks later, the patient presented to the hos­pital with a four day history of low-grade fever and turbid peritoneal dialysis (PD) fluid asso­ciated with anorexia and abdominal tender­ness. The exit site had a whitish discharge. Peritoneal fluid cell count revealed 180 nuc­leated cells/mm [3] (54% polymorphonuclear cells, 44% mono-nuclear cells) and 12 red blood cells/mm [3] , and gram stain was negative. The patient was admitted to the hospital and started on Vancomycin and Gentamycin empirically. Zeil Neilson (ZN) stain was reported positive for acid-fast bacilli (AFB) Routine cultures were negative, but automated AFB cultures (BACTEC, MIGIT 960, Bacten Dickenson, Baltimore, MD, USA) grew NTM. Further identification by nucleic acid probe (BIOSCENTIA, Ingelheim, Germany) identified the organism as Mycobacterium abscesses in six days time, sensitive to Amikacin and Cla-rithromycin. The Tenckhoff catheter was re­moved and the patient was shifted to hemo-dialysis. Exit site discharge and tip of the Tenckhoff catheter also grew M. abscesses. The patient received Amikacin and Clarithro-mycin for eight weeks and was continued on hemodialysis. There was no evidence of pul­monary or lymph node involvement by CT scans. Blood C/S remained negative. Clinically recovery was noted after four weeks with negative repeat cultures.

Case 2

A 64-year-old Saudi female with adult-onset diabetes on CAPD presented 1 year after ini­tiation with a two day history of abdominal pain and diarrhea.

Clinical diagnosis of peritonitis was made. PD fluid revealed 214 nucleated cells/mm [3] (58% polymorphonuclear cells, 42% mono-nuclear cells). She was started on Vancomycin and Gentamycin while waiting for laboratory results. ZN stain was positive for AFB. Cul­ture specimens grew NTM within four days. Nucleic acid probe reported the organism as M. abscesses, resistant to Amikacin, Cefoxitin, and Ciprofloxacin, but sensitive to Clarithro-mycin. Tenckhoff catheter was removed and a peritoneal biopsy was taken. Catheter tip cul­ture was also positive for M. abscesses. The biopsy was reported as fibrous tissue with epithelioid granuloma and areas of caseating necrosis. ZN stain was also positive for AFB in the biopsy [Figure 1] and [Figure 2]. The patient received Clarithromycin for three months and she was shifted to hemodialysis.
Figure 1: Group of histiocytes in peritoneal biopsy.

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Figure 2: Zeil Neilsen stain of peritoneal biopsy showing AFB.

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   Discussion Top


There are more than 100 species of NTM and nearly half are known to cause disease. [2] Histo­rically this group of organisms was labeled as "atypical mycobacterium." Runyon proposed the first classification in 1959 using the colony growth rate and morphology. The rapidly gro­wing mycobacteria show growth with-in 3-7 days on agar plate medium, while the slow-growing mycobacteria require >7 days and the intermediate growing groups show growth within 7-10 days. [3] The rapid growers are gram-positive rods that resemble diphtheroids. The Runyon classification has become less useful due to newer methods of diagnosis. The National Committee for Clinical Laboratory Stan-dards (NCCLS) recommends agar plate, broth microdilution and macrodilution (BAC-TEC or similar system), as methods of choice. [4] Polymerase chain reaction can also be used to assist in early diagnosis. [5] Most NTM are present in environment, in soil and water. M. abscesses belongs to the group of rapidly growing mycobacteria and it mostly causes pulmonary disease [2] along with community-acquired infections of skin and soft tissue in normal and immunosuppressed hosts. The reason for these outbreaks has been generally municipal or distilled (hospital) water supplies. [6]

NTM is a less common cause of peritonitis in CAPD patients. Nevertheless, several cases have been reported from all over the world, with Mycobacterium fortuitum being the most common organism [7] along with Mycobacterium avium, [8] Mycobacterium chelonae, [9] Mycobac-terium gordonae, [10] Mycobacterium gastri, [11] and Mycobacterium kansasii. [12] No cases of catheter-related infection or peritonitis have been reported with M. abscesses in CAPD pa­tients, to the best of our knowledge.

Both of our patients had positive cultures of M. abscesses from PD fluid as well as exit site. We postulate that the possible route of in­fection was the formation of a small abscess or tunnel infection with subsequent seeding of the peritoneal cavity. Direct inoculation of conta­minated water through the PD catheter seems less likely.

Reactivation of a latent focus could be a possibility but is not reported with NTM. In­fection by Mycobacterium necessitates the re­moval of Tenckhoff catheters as in fungal in-fection. [13],[14] Delay in catheter removal could risk the life of the patient. [8] Our patients were diagnosed to have infection with AFB within 24 hours and confirmation with positive cul­ture was available in less than two weeks time. The NTM are said to be resistant to first-line anti-tuberculous drugs. [15] Most of the NTM are reported to be sensitive to the macrolides (Cla-rithromycin, Azithromycin), quinolones (Ci-profloxacillin), and Trimethoprim-Sulfmetha-xazole. [15] The therapy would depend on the species of NTM as certain species do respond well to Rifampin and Ethambutol (M. gordo-nae, M. kansasii). [15] Monotherapy has not been recommended because of the potential for resistance. There is no consensus on the com­bination of antibiotics or the duration of treat­ment. In general, antibiotics should be con­tinued until complete eradication is achieved and all cultures become negative.

We used Clarithromycin in both the cases and used it as monotherapy in one case with no complications. Our duration of treatment, based on repeated negative cultures, was also shorter than what is reported in the literature, probably because of early removal of the Tenckhoff catheters. One of our patients had clear fluid on presentation, which stresses the importance of clinical suspicion of peritonitis.

In endemic areas, ZN staining should be included in the evaluation of peritonitis in CAPD patients. Tenckhoff catheter should be removed regardless of the clinical response. Since the Mycobacterium can be cultured in a few days, repeated negative cultures can be considered as complete eradication. Second-line antituberculous drugs are effective in treating NTM in CAPD peritonitis and should be started early.

 
   References Top

1.Abdelrahman M, Sinha A, Karkar A. Tuber­culosis in end-stage renal disease patients on hemodialysis. Hemdial Int 2006;10:360-4.  Back to cited text no. 1
    
2.Brown-Elliot BA, Wallace RJ. Infections caused by nontuberculous mycobacteria. In Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases, 6th ed. Churchill Livingstone 2005;251:2909-16.  Back to cited text no. 2
    
3.Brown-Elliot BA, Wallace RJ. Clinical and Taxonomic status of pathogenic non-pig-mented rapidly growing mycobacteria. Clin Microbiol Rev 2002;15:716-46.  Back to cited text no. 3
    
4.Woods GL, Brown-Elliot BA, Desmond PA, et al. Susceptibility testing of mycobacteria, Nocardia and other aerobic Actinomyces. 2 nd Ed. National Committee for clinical laboratory standards Pub V 2.0. NCCLS: 2003:M24: A  Back to cited text no. 4
    
5.Dervisoglu E. Sayan M. Sengul E. Yilmaz A. Rapid diagnosis of Mycobacterium tuberculous peritonitis with real-time PCR in a peritoneal dialysis patient. APMIS 2006;114:656-8,  Back to cited text no. 5
    
6.Maloney S, Welbel S, Daves B, et al. Myco-bacterium abscessus pseudoinfection traced to an automated endoscope washer: utility of epidemiologic and laboratory investigation. J Infec Dis 1994;169:1166-9.  Back to cited text no. 6
    
7.Woods GL, Hall GS, Schreiber MJ. Myco-bacterium fortuitum peritonitis associated with continuous ambulatory peritoneal dialysis. J Clin Microbiol 1986;23(4):786-8.  Back to cited text no. 7
    
8.Pulliam JP, Vernon DD, Alexander SR, Hartstein AI, Golper TA. Nontuberculous mycobacterial peritonitis associated with con­tinuous ambulatory peritoneal dialysis. Am J Kidney Dis 1983;2(6):610-4.  Back to cited text no. 8
    
9.Poisson M, Beroniade V, Falardeau P, Vega C, Morriset R. Mycobacterium Chelonei peri­tonitis peritonitis in a patient undergoing con­tinuous ambulatory peritoneal dialysis (CAPD). Perit Dial Bull 1983;3:86-8.  Back to cited text no. 9
    
10.London RD, Damsker B, Neibart EP, Knorr B, Bottone EJ. Mycobacterium gordonae: an unusual peritoneal pathogen in a patient under­going continuous ambulatory peritoneal dia­lysis. Am J Med 1988;85:703-4.   Back to cited text no. 10
[PUBMED]    
11.Linton IM, Leahy SI, Thomas GW. Mycobac-terium gastri peritonitis in a patient undergoing continuous ambulatory peritoneal dialysis. Aust N Z J Med 1986;16:224-5.  Back to cited text no. 11
[PUBMED]    
12.Giladi M, Lee BE, Berlin OG, Panosian CB. Peritonitis caused by Mycobacterium kansasii in a patient undergoing continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1992; 19:597-9.  Back to cited text no. 12
[PUBMED]    
13.Kleinpeter M, Krane N. Treatment of myco-bacterial exit-site infections in patients on continuous ambulatory peritoneal dialysis. Adv Perit Dial 2001;17:172-5.  Back to cited text no. 13
    
14.Harro C, Braden GL, Morris AB, Lipkowitz GS, Madden RL. Failure to cure Mycobac-terium gordonae peritonitis associated with continuous ambulatory peritoneal dialysis. Clin Infect Dis 1997;24:955-7.  Back to cited text no. 14
[PUBMED]  [FULLTEXT]  
15.Rho M, Bia F, Brewster UC. Nontuberculous mycobacterial peritonitis in peritoneal dialysis patients. Semin Dial 2006;20:271-6.  Back to cited text no. 15
    

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Correspondence Address:
Nauman Siddiqi
Division of Nephrology, Department of Medicine, King Fahd Armed Forces Hospital, P.O. Box 9862, Jeddah 21159
Saudi Arabia
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PMID: 22382227

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    Figures

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    Abstract
   Introduction
   Case Report
   Discussion
    References
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