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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2017  |  Volume : 28  |  Issue : 3  |  Page : 670-671
Peritonitis associated with infective endocarditis and vertebral osteomyelitis in a peritoneal dialysis patient

Department of Internal Medicine, Division of Nephrology, Changhua Christian Hospital, Changhua, 500, Taiwan, Republic of China

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Date of Web Publication18-May-2017

How to cite this article:
Wen YK. Peritonitis associated with infective endocarditis and vertebral osteomyelitis in a peritoneal dialysis patient. Saudi J Kidney Dis Transpl 2017;28:670-1

How to cite this URL:
Wen YK. Peritonitis associated with infective endocarditis and vertebral osteomyelitis in a peritoneal dialysis patient. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2021 Mar 6];28:670-1. Available from: https://www.sjkdt.org/text.asp?2017/28/3/670/206466
To the Editor,

Peritonitis is one of the major complications of peritoneal dialysis (PD) and remains the leading cause for withdrawal in PD patients.[1] PD-related peritonitis is most often due to touch contamination with pathogenic skin bacteria or to catheter-related infection. Secondary peritonitis caused by hematogenous spread is extremely rare. We report an unusual case of peritonitis associated with infective endo-carditis and vertebral osteomyelitis in a PD patient. Systemic bacteremia is believed to be the main culprit. To our knowledge, this is the first report in literature.

A 39-year-old female with end-stage renal disease due to chronic glomerulonephritis had been maintained on continuous ambulatory PD for five years uneventfully. She had no past history of rheumatic heart disease and her previous cardiac evaluation was normal. The patient was admitted to our hospital because of cloudy peritoneal effluent accompanied by abdominal pain that began few hours before admission. Furthermore, she had been afflicted with low back pain and intermittent fever for one week before admission. On physical examination, high body temperature of 38.5°C, diffuse abdominal tenderness, and lower back knocking pain were noted. The PD catheter exit site was clean and there were no signs of tunnel infection. Neurologic assessment revealed decreased muscle power of the left lower limb. Laboratory tests were remarkable for peripheral white blood cell (WBC) count of 28,000/mm3 and hemoglobin level of 6.9 g/dL. The WBC count in the peritoneal fluid was 3925/mm3 (83% neutrophils). A Gram- stain of the centrifuged dialysis effluent revealed Gram-positive microorganisms. Antibiotic treatment with intraperitoneal vanco- mycin was initiated and then changed into parenteral oxacillin when the cultures of PD effluent and blood both reported to grow oxacillin-sensitive Staphylococcus aureus. Due to lower back pain accompanied by left leg weakness, magnetic resonance imaging of the lumbar spine was arranged, and vertebral osteomyelitis affecting S1 joint with abscess in the left lower iliacus muscle, bilateral erector spinae muscles, and left gluteus muscles was disclosed. Due to heart murmurs, echocardio- graphy was arranged and showed vegetation (2.33 cm x 0.83 cm) over the aortic valve. Although the abdominal pain improved and PD effluent became clear soon after antibiotic treatment, other infectious signs including fever, leukocytosis, and S. aureus bacteremia continued to be noted over 10 days after admission. Due to uncontrolled infection, aortic valve replacement surgery was performed. The patient was eventually discharged with a stable condition after two-month hospital stay. Mild left leg weakness remained. She was switched to hemodialysis due to ultrafiltration failure of PD.

In our patient, the history of the present illness suggested vertebral osteomyelitis preceding the appearance of peritonitis. Vertebral osteomyelitis most often occurs as a result of hematogenous spread from a distant focus and is a well-recognized complication of infective endocarditis.[2] It is probable that the subsequent development of peritonitis was also associated with systemic bacteremia. Furthermore, uncontrolled infection continued to be noted after PD effluent became clear, indicating that persistent bacteremia was caused by other infection focus rather than by unresolved peritonitis. Therefore, we believe that the primary infection focus was infective endocarditis in this PD patient. Reviewing of literature, only two reports of PD peritonitis associated with infective endocarditis are available. In the first case, infective endocarditis was diagnosed two months after an episode of peritonitis and the causal relationship was unclear.[3] The second case documented infective endocarditis giving rise to peritonitis, in which persistent Streptococcus equinus bacte- remia prompted further search for infection source.[4] Infective endocarditis is associated with a high mortality and a broad array of complications. In addition to adequate antibiotic treatment, surgical treatment should be considered in patients with heart failure, uncontrolled infection, and for prevention of embolic events.[5]

In conclusion, this case suggests that hematogenous source of peritonitis should be kept in mind in PD patients with concomitant extra-abdominal manifestations and persistent bacteremia.

Conflict of interest: None declared.

   References Top

Voinescu CG, Khanna R. Peritonitis in peritoneal dialysis. Int J Artif Organs 2002; 25:249-60.  Back to cited text no. 1
Speechly-Dick ME, Swanton RH. Osteomyelitis and infective endocarditis. Postgrad Med J 1994;70:885-90.  Back to cited text no. 2
Youmbissi JT, Al Saif S, Malik TQ. Culture negative endocarditis after CAPD peritonitis: True or fortuitous association? Saudi J Kidney Dis Transpl 2001;12:550-2.  Back to cited text no. 3
[PUBMED]  [Full text]  
Tsai MJ, Yang WC, Chen TW, Lin CC. Infective endocarditis giving rise to peritonitis in a patient on peritoneal dialysis. Perit Dial Int 2013;33:462-3.  Back to cited text no. 4
Bannay A, Hoen B, Duval X, et al. The impact of valve surgery on short- and long-term mortality in left-sided infective endocarditis: Do differences in methodological approaches explain previous conflicting results? Eur Heart J 2011;32:2003-15.  Back to cited text no. 5

Correspondence Address:
Dr. Yao-Ko Wen
Department of Internal Medicine, Division of Nephrology, Changhua Christian Hospital, Changhua, 500, Taiwan
Republic of China
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DOI: 10.4103/1319-2442.206466

PMID: 28540916

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