Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
Year
: 2019  |  Volume : 30  |  Issue : 1  |  Page : 250--253

A rare agent of continuous ambulatory peritoneal dialysis peritonitis: Rhizobium Radiobacter


Andaç Karadeniz1, H Ahmet Aydemir2, M Hamidullah Uyanık3, Abdullah Uyanık4, Erdem Çankaya4,  
1 Department of Internal Medicine, Faculty of Medicine, Atatürk University, Erzurum, Turkey
2 Department of Family Medicine, Faculty of Medicine, Atatürk University, Erzurum, Turkey
3 Department of Medical Microbiology, Faculty of Medicine, Atatürk University, Erzurum, Turkey
4 Department of Nephrology, Faculty of Medicine, Atatürk University, Erzurum, Turkey

Correspondence Address:
Andaç Karadeniz
Department of Internal Medicine, Faculty of Medicine, Atatürk University, Erzurum
Turkey

Abstract

Peritonitis is a common clinical problem in patients treated by continuous ambulatory peritoneal dialysis (CAPD). The most common microbiological factors causing peritonitis are Gram-positive (especially Staphylococcus spp.). Peritonitis with Rhizobium radiobacter (Agrobacterium radiobacter) is a rare infection in CAPD patients. Peritonitis due to R. radiobacter has been reported in our patient's dialysate culture who underwent CAPD for three years. We report the case of a 26-year-old female PD patient who had CAPD peritonitis due to R. radiobacter and successfully treated with intraperitoneal vancomycin and oral ciprofloxacin without relapses or removing the PD catheter.



How to cite this article:
Karadeniz A, Aydemir H A, Uyanık M H, Uyanık A, Çankaya E. A rare agent of continuous ambulatory peritoneal dialysis peritonitis: Rhizobium Radiobacter.Saudi J Kidney Dis Transpl 2019;30:250-253


How to cite this URL:
Karadeniz A, Aydemir H A, Uyanık M H, Uyanık A, Çankaya E. A rare agent of continuous ambulatory peritoneal dialysis peritonitis: Rhizobium Radiobacter. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Sep 15 ];30:250-253
Available from: http://www.sjkdt.org/text.asp?2019/30/1/250/252920


Full Text



 Introduction



Peritonitis is the most important complication of peritoneal dialysis (PD).[1] At least two of the following three conditions are required for peritonitis diagnosis: (1) Symptoms and signs of peritoneal inflammation; (2) Increased number of peritoneal fluid cells (leukocyte >100/ mm3), especially increased neutrophils (polymorphonuclear) leukocyte >50%) and cloudy fluids; (3) Demonstration of the presence of bacteria in the peritoneal space with Gram-staining or culture.[2],[3] Studies on the etiology of continuous ambulatory PD (CAPD) peritonitis have shown that Gram-positive microorganisms are often associated with peritonitis. More rarely, peritonitis cases involving Gramnegative microorganisms have been reported, and it has been reported that treatment of these cases is more difficult.[4] In this study, we present a case of CAPD peritonitis due to Rhizobium radiobacter (Agrobacterium radio-bacter) in our clinic.

 Case Report



A 26-year-old female patient with end-stage renal failure due to focal segmental glomerulosclerosis on PD for three years, presented with complaints of pain in abdomen, cloudy dialysate fluid, nausea, and vomiting for two days. On physical examination the following were observed: tension arterial: 120/70 mm Hg (brachial) and fever: 36.2°C (axillary). There was minimal sensitivity around the periumbital area, and around the peritoneal catheter, there was no rebound and no defenses in the abdomen. At the time of admission, the patient was diagnosed with SAPD peritonitis on a white blood cell (WBC: 400/mm3 in the PD fluid). After the blood and peritoneal dialysate cultures were taken, treatment including empirical intraperitoneal 1 g vancomycin for every four days and oral 250 mg ciprofloxacin 3  1/day was started. On other laboratory tests, the blood WBC was 7210/mm3, erythrocyte sedimentation rate was 68 mm/h, and C-reactive protein was 72.1 mg/L (normal range: 0–5 mg/L). R. radiobacter was found in peritoneal dialysate culture. The antibiogram could not be documented because this pathogen is rarely isolated in cultures. The treatment of the patient who had improvement in complaints and laboratory findings was not changed. In total, three doses of intraperitoneal 1 g vancomycin and eight doses of oral 250 mg of ciprofloxacin 3 × 1/day were given. On the 8th day of follow-up, WBC value in the peritoneal dialysate fluid was 10/mm3 [Table 1]. The treatment was completed in 14 days. Unlike the patients with the same microbiological agent, our patient was discharged completely without the necessity of removing the PD catheter. In the following days, none of the relapse or reinfection peritonitis was found in our patent, which was a gladsome result against the same cases in literature.{Table 1}

 Discussion



Peritonitis is the most common complication in patients with end-stage renal disease treated with PD. Gram-positive bacteria such as Staphylococcus aureus which is found in normal skin flora causes 60%–80% of CAPD peritonitis and the remaining 20% is caused by Gram-negative, anaerobic, fungal, and mixed infections.[5] Peritonitis due to Gram-negative organisms may be caused by transmural migration due to diverticulitis, colitis, constipation, etc., or it may also result in contamination with touch. Compared with other peritonitis, patients with peritonitis due to Gramnegative factors have higher rates of hospitalization, peritoneal catheter removal, and six month mortality.[6],[7] Rhizobium spp., formerly known as Agrobacterium and reclassified to 16S rDNA analyzes, are aerobic, mobile, oxidase-positive, and nonspore-forming Gramnegative bacilli.[8],[9],[10],[11] R. radiobacter is considered as the most opportunistic human pathogen among Rhizobium species (R. radiobacter, Rhizobium rhizogenes, Rhizobium rubi, Rhizobium undicola, and Rhizobium vitis).[6],[8],[9] R. radiobacter related infections are usually secondary to the use of intravenous catheters.[12],[13] It is important to examine the peritoneal fluid with Gram-staining in the planning of empirical treatment of peritonitis in CAPD patients. Intraperitoneal vancomycin is recommended with intraperitoneal or intravenous ceftazidime or ciprofloxacin if no causative microorganism is present in direct Gramstaining.[14] In literature, peritonitis cases which are related with R. radiobacter are very rare, and there are cases requiring removal of peritoneal catheter due to recurrence and resistant peritonitis.[13],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25] In conclusion, R. radiobacter is a rare microbiological agent that may relapse or may require removal of peritoneal catheter. In our case, this agent was treated with intraperitoneal vancomycin and oral ciprofloxacin without re-infection and without the necessity of removing the peritoneal catheter.

References

1Van Diepen AT, Tomlinson GA, Jassal SV. The association between exit site infection and subsequent peritonitis among peritoneal dialysis patients. Clin J Am Soc Nephrol 2012; 7:1266-71.
2Leeney DJ, Gandhi VC, Daugrrdas JT. Capd peritonitis. In: Daugirdas JT, Anding TS, editors. Handbook of Dialysis. Boston/Toronto: Little Brown; 1988. p. 252-73.
3Khanna R, Nolph KD, Oraeopulas DG. Peritonitis and exit-site infection. In: The Essentials of Peritoneal Dialysis. Dortecht, Boston London: Kluwer Academic Publishers; 1993. p. 76-88.
4Çankaya E, Keleş M, Uyanık A, Gülcan E, Birdal C, Bilen Y, et al. Peritonitis in peritoneal dialysis patients vectors rare: klebsiella pneumonia. Van Medical Journal 23(1):90-91, 2016
5Quintanar Lartundo JA, Palomar R, et al. Microbiological profile of peritoneal dialysis peritonitis and predictors of hospitalization. Adv Perit Dial 2011;27:38-42.
6Prasad N, Gupta A, Sharma RK, Prasad KN, Gulati S, Sharma AP. Outcome of grampositive and gram-negative peritonitis in patients on continuous ambulatory peritoneal dialysis: A single-center experience. Perit Dial Int 2003;23 Suppl 2:S144-7.
7Troidle L, Gorban-Brennan N, Kliger A, Finkelstein F. Differing outcomes of grampositive and gram-negative peritonitis. Am J Kidney Dis 1998;32:623-8.
8Edmond MB, Riddler SA, Baxter CM, Wicklund BM, Pasculle AW. Agrobacterium radiobacter: A recently recognized opportunistic pathogen. Clin Infect Dis 1993;16:388-91.
9Lai CC, Teng LJ, Hsueh PR, et al. Clinical and microbiological characteristics of Rhizobium radiobacter infections. Clin Infect Dis 2004; 38:149-53.
10Kersters K, De Ley J. Genus III. Agrobacterium Conn, In: Krieg NR, J. Holt JG, editors. Bergey's Manual of Systematic Bacteriology. Vol. 1. The Williams & Wilkins Co., Baltimore; 1984. p. 244-54.
11Young JM, Kuykendall LD, Martínez-Romero E, Kerr A, Sawada H. A revision of Rhizobium Frank 1889, with an emended description of the genus, and the inclusion of all species of Agrobacterium conn 1942 and Allorhizobium undicola de lajudie et al 1998 as new combinations: Rhizobium radiobacter, R. rhizogenes, R. rubi, R. undicola and R. vitis. Int J Syst Evol Microbiol 2001;51:89-103.
12Potvliege C, Vanhuynegem L, Hansen W. Catheter infection caused by an unusual pathogen, Agrobacterium radiobacter. J Clin Microbiol 1989;27:2120-2.
13Rodby RA, Glick EJ. Agrobacterium radiobacter peritonitis in two patients maintained on chronic peritoneal dialysis. Am J Kidney Dis 1991;18:402-5.
14Daugirdas JT. Dialysis Hand Book. Istanbul: Nobel Medical Publishers; 1997.
15Badrising S, Bakker L, Lobatto S, van Es A. Peritonitis in a peritoneal dialysis patient due to Rhizobium radiobacter and Moraxella osloensis: Case report and literature review. Perit Dial Int 2014;34:813-5.
16Misra R, Prasad KN, Singh K, Bhadauria D, Sharma RK. Rhizobium radiobacter peritonitis: The first case report from İndia and review. JMM Case Rep 2014;1:e004051.
17Chao CM, Tsai TC, Lai CC. Secondary peritonitis due to Rhizobium radiobacter. Surg Infect (Larchmt) 2014;15:141-3.
18Tsai SF. Rhizobium radiobacter peritonitis revisited: Catheter removal is not mandatory. Perit Dial Int 2013;33:331-2.
19Marta R, Dâmaso C, Silva JE, Almeida M. Peritonitis due to Rhizobium radiobacter. Einstein (Sao Paulo) 2011;9:389-90.
20Rothe H, Rothenpieler U. Peritonitis due to multiresistant Rhizobium radiobacter. Perit Dial Int 2007;27:214-5.
21Minguela JI, de-Pablos M, Castellanos T, Ruiz-de-Gauna R. Peritonitis by Rhizobium radiobacter. Perit Dial Int 2006;26:112.
22Levitski-Heikkila TV, Ullian ME. Peritonitis with multiple rare environmental bacteria in a patient receiving long-term peritoneal dialysis. Am J Kidney Dis 2005;46:e119-24.
23Lui SL, Lo WK. Agrobacterium radiobacter peritonitis in a Chinese patient on CAPD. Perit Dial Int 2005;25:95.
24Jankauskiene A, Baciulis V, Baliukynaite V, Kaltenis P. Peritonitis caused by Agrobacterium tumefaciens in a child on peritoneal dialysis. Nephrol Dial Transplant 2003;18:2456-7.
25Melgosa Hijosa M, Ramos Lopez MC, Ruiz Almagro P, Fernandez Escribano A, Luque de Pablos A. Agrobacterium radiobacter peritonitis in a Down's syndrome child maintained on peritoneal dialysis. Perit Dial Int 1997;17:515.