| Abstract|| |
Eosinophilic peritonitis (EP) is an uncommon complication of peritoneal dialysis, which happens usually secondary to either an underlying bacterial, fungal or tubercular infection or as a reaction to intraperitoneal drugs or constituents of the dialysis system like tubings or solution. We report a case of a middle aged male who was initiated on continuous ambulatory peritoneal dialysis. Because of inadequate inflow and outflow of dialysis fluid, he was given two doses of intraperitoneal streptokinase after ruling out other causes. After the use of intraperitoneal streptokinase, there was turbid effluent with culture showing Staphylococcus aureus. Even after the successful treatment of bacterial peritonitis with intravenous antibiotics, he continued to have turbid effluent, with a predominance of eosinophils in the effluent cell count. A diagnosis of EP was made and he was managed with the antihistaminic drug loratidine, with complete resolution.
|How to cite this article:|
Rathi M. Intraperitoneal streptokinase use-associated eosinophilic peritonitis. Saudi J Kidney Dis Transpl 2015;26:128-31
| Introduction|| |
Eosinophilic peritonitis (EP) is an infrequently described problem in patients on continuous ambulatory peritoneal dialysis (CAPD). We report a case of EP that followed the use of intraperitoneal streptokinase and responded promptly to oral administration of loratidine.
| Case Report|| |
A 54-year-old non-diabetic man was diagnosed as end-stage renal disease and initiated on maintenance hemodialysis (MHD). Because of the non-availability of an MHD facility near his place, he planned a shift to peritoneal dialysis. He underwent Tenchkoff catheter insertion by the open surgical method and was admitted for initiation of CAPD. However, there was poor fluid inflow and outflow with normal catheter position, normal blood sugars and no constipation. After ruling out the usual causes of mechanical obstruction, a trial of intraperitoneal (i.p.) streptokinase was given. A dose of 750,000 IU of streptokinase was diluted in 100 mL of normal saline and infused into the peritoneal catheter over a period of 60 min. The catheter was clamped for 24 h and a repeat dose was given after 72 h. After 24 h of the first dose, his outflow improved along with marked turbidity of CAPD effluent and poor ultrafiltration. Analysis of peritoneal fluid revealed a total leukocyte count (TLC) of 1500/μL, with 95% polymorphs. He was started on intravenous (i.v.) vancomycin and i.v. ceftazidime after sending fluid cultures, which subsequently revealed Staphylococcus aureus, and antibiotics were appropriately changed to i.v. cephalozin and i.v. ciprofloxacin. After six days of antibiotic therapy, fluid turbidity persisted with TLC of 800/μ L and 70% neutrophils. Repeat cultures were sterile and, as the patient was asymptomatic with improvement in ultrafiltration, he was continued on the same antibiotics. Even after two weeks of antibiotics therapy, the turbidity of fluid persisted and fluid analysis revealed a TLC of 1800/μL with 54% neutrophils and 46% eosinophils. Suspecting EP, fluid was sent for bacterial and fungal cultures as well as acid-fast bacilli staining and cultures, all of which turned out to be negative. He denied any history of atopy or allergic diathesis and there was no elevation of eosinophil count in blood. Etiology of EP was suspected to be due to the use of intraperitoneal streptokinase. He was not given any further dose of streptokinase and was started on tablet loratidine and, within 48 h, his peritoneal fluid was clear and repeat fluid analysis showed a total count 50 cells with 97% lymphocytes and 3% eosinophils. His antibiotics were continued for four weeks along with tablet loratidine and he was doing fine at one year.
| Discussion|| |
EP was first described by Lee and Schoen in 1967.  The incidence of EP is quite variable; while, the initial studies reported an incidence as high as 60%, it was less in the subsequent studies. ,, The etiology is unclear but has been hypothesized as an allergic reaction to various agents such as air or blood introduced at the time of surgery, constituents of catheter or tubing or intraperitoneal drugs. , Icodextrin has also been reported to cause chemical peritonitis with eosinophilor monocyte-induced turbidity.  It has also been reported in association with bacterial or fungal infections. 
Diagnosis of EP should be suspected when there is turbid effluent with repeated negative cultures, and the antibiotic treatment seems ineffective. Diagnosis is confirmed by the presence of >100 WBC/μ L with >10% eosinophils. ,, EP usually follows a benign self-limiting course and does not impair the structure or function of peritoneum and hence catheter removal is not indicated; however, it may mask a genuine infective episode or cause excessive peritoneal protein loss.
Streptokinase is a polypeptide with a molecular weight of 47 KD and is a powerful activator of fibrinolysis. Systemic infusion of streptokinase has been used since long in coronary artery occlusion, pulmonary thromboembolism and occlusive peripheral vascular disease,  while localized infusion has been used successfully to treat occluded external hemodialysis shunts and catheters.  Systemic streptokinase use can cause fever, chills, allergic reactions, bleeding complications and, rarely, anaphylaxis. However, because of its large molecular weight and rapid clearance, there is no evidence of systemic absorption after oral, rectal or i.p. administration.  It has been postulated that bacteria causing peritonitis may get sequestrated in the fibrin thrombi present in the intra-abdominal compartment or catheter and may contribute to resistance to therapy, causing refractory or recurrent peritonitis. Although antibiotics remain the cornerstone for the treatment of these cases, modified treatment protocols using i.p. infusion of streptokinase or urokinase have been used successfully to treat such patients, obviating the need of catheter removal. , Williams et al performed a randomized trial comparing catheter replacement and i.p. urokinase in cases of recurrent CAPD peritonitis.  While 14 patients remained free of peritonitis after catheter replacement, five out of 17 patients were peritonitis free following urokinase therapy. Streptokinase has also been used in the management of obstructed catheters. Thompson and Uldall in 1969 first described the use of streptokinase to declot the peritoneal catheter. 
Subsequently, more reports have been published with successful outcome. , Wiegmann and colleagues  used i.p. streptokinase during 19 episodes of catheter failure in 16 patients. There were 13 successful attempts to re-establish catheter flow in 11 patients. The successful outcome occurred typically in those patients who had intra-abdominal bleeding or fibrin clot formation after recent surgery. Our case also had placement of catheter just two weeks back, and the obstruction was due to fibrin plugs, resulting in successful treatment. Interestingly, as in our case, Wiegmann et al have also observed few cases of bacterial peritonitis after infusion of i.p. streptokinase,  and we postulate that introduction of i.p. streptokinase leads to dissolution of fibrin plugs and breaking of intra-abdominal loculations harboring the infected fluid and aid in the drainage of cloudy effluent. Although there have been occurrences of hemorrhagic effluent or bacterial peritonitis after the use of i.p. streptokinase, we were unable to find any report of EP developing after the use of i.p. streptokinase. We have suspected the etiology of EP in our case to be due to i.p. streptokinase, as it occurred two weeks after its administration; there was no other drug used intraperitoneally; microbiological work-up was negative for bacterial, fungal or tubercular infections and he was not on icodextrin therapy. Another possibility was idiopathic or catheter-associated EP, which cannot be excluded beyond doubt.
Although there is no specific therapy for EP, antihistaminic drugs and oral or i.p. steroids have been used. ,, Administration of steroids has been recommended only in the presence of severe abdominal pain or hypoalbuminemia or to maintain catheter patency if fluid is markedly turbid.  Treatment with these drugs is usually prescribed for four weeks or more, as the shorter duration is associated with recurrence.
In summary, this is the first reported case of EP associated with use of i.p. streptokinase to the best of our knowledge. The present case highlights the importance of careful analysis of differential counts of peritoneal fluid; else, this case might have been misdiagnosed as refractory culture-sterile peritonitis leading to catheter removal.
| References|| |
Lee S, Schoen I. Eosinophilia of peritoneal fluid and peripheral blood associated with chronic peritoneal dialysis. Am J Clin Pathol 1967;47:638-40.
Chan MK, Chow I, Lam SS, Jones B. Peritoneal eosinophilia in patients on continuous ambulatory peritoneal dialysis: A prospective study. Am J Kidney Dis 1988;11:180-3.
Quinlan C, Cantwell M, Rees L. Eosinophilic peritonitis in children on chronic peritoneal dialysis. Pediatr Nephrol 2010;25:517-22.
Jo YI, Song JO, Park JH, Lee JH, Shin SK. Idiopathic eosinophilic peritonitis in continuous ambulatory peritoneal dialysis: Experience with percutaneous catheter placement. Nephrology 2007;12:437-40.
Daugirdas JT, Leehey DJ, Popli S, et al. Induction of peritoneal fluid eosinophilia and/ or monocytosis by intraperitoneal air injection. Am J Nephrol 1987;7:116-20.
Rosner MH, Chhatkuli B. Vancomycin-related eosinophilic peritonitis. Perit Dial Int 2010;30:650-2.
Tintillier M, Pochet JM, Christophe JL, Scheiff JM, Goffin E. Transient sterile chemical peritonitis with icodextrin: Clinical presentation, prevalence and literature review. Perit Dial Int 2002;22:534-7.
Sridhar R, Thornley Brown D, Kant KS. Peritonitis due to Aspergillus niger: Diagnostic importance of peritoneal eosinophilia. Perit Dial Int 1990;10:100-1.
Brogden RN, Speight TM, Avery MS. Streptokinase: A review of its clinical pharmacology, mechanism of action and therapeutic uses. Drugs 1973;5:357-445.
Cocke TB, Burgos-Calderon RA, Gonzales FM. The use of streptokinase infusions for arteriovenous shunt declotting. Trans Am Soc Art Intern Organs 1970;16:292-6.
Oliven A, Gidron E. Orally and rectally administered streptokinase. Investigation of its absorption and activity. Pharmacol 1981;22:135-8.
Wiegmann TB, Stuewe B, Duncan KA, et al. Effective use of streptokinase for peritoneal catheter failure. Am J Kidney Dis 1985;6:119-23.
Williams AJ, Boletis I, Johnson BF, et al. Tenckhoff catheter replacement or intraperitoneal streptokinase: A randomized trial in the management of recurrent continuous peritoneal dialysis (CAPD) peritonitis. Perit Dial Int 1989;9:65-7.
Thompson N, Uldall R. A problem in peritoneal dialysis. Lancet 1969;2:602-3.
Palacios M, Schley W, Dougherty J. Use of streptokinase to clear peritoneal catheters. Dial Transplant 1982;11:172-4.
Tarng DC, Chen TW, Chen CH. Peritonitis in CAPD patient--do not always use antibiotics. Nephrol Dial Transplant 2001;16:856-8.
Tang S, Lo CY, Lo WK, Chan TM. Resolution of eosinophilic peritonitis with Ketotifen. Am J Kidney Dis 1997;30:433-6.
Thakur SS, Unikowsky B, Prichard S. Eosinophilic peritonitis in continuous ambulatory peritoneal dialysis: Treatment with prednisolone and diphenhydramine. Perit Dial Int 1997;17:402-3.
Dr. Manish Rathi
Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012