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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2018  |  Volume : 29  |  Issue : 1  |  Page : 189-192
Suttonella indologenes peritonitis in a patient receiving continuous ambulatory peritoneal dialysis

1 Department of Internal Medicine, Karabuk University, Karabuk, Turkey
2 Department of Nephrology, Karabuk University, Karabuk, Turkey
3 Department of Cardiology, Faculty of Medicine, Karabuk University, Karabuk, Turkey

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Date of Web Publication15-Feb-2018


Suttonella indologenes is a Gram-negative, aerobic coccobacillus of Cardiobacteriaceae family and its natural habitat is the mucous membranes of the upper respiratory system. The literature includes limited number of case reports concerning fatal endocarditis due to infection in the prosthetic heart valves caused by the aforementioned microorganism. However, there is no information on extracardiac involvement due to this microorganism. Here, we present a peritonitis case caused by Suttonella indologenes in a patient receiving continuous ambulatory peritoneal dialysis.

How to cite this article:
Sevencan NO, Bakirdogen S, Adar A, Kayhan B. Suttonella indologenes peritonitis in a patient receiving continuous ambulatory peritoneal dialysis. Saudi J Kidney Dis Transpl 2018;29:189-92

How to cite this URL:
Sevencan NO, Bakirdogen S, Adar A, Kayhan B. Suttonella indologenes peritonitis in a patient receiving continuous ambulatory peritoneal dialysis. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2021 Apr 10];29:189-92. Available from: https://www.sjkdt.org/text.asp?2018/29/1/189/225200

   Introduction Top

Peritonitis is the most common complication of continuous ambulatory peritoneal dialysis (CAPD).[1],[2] In general, Gram-positive microorganisms play a role in the etiology of CAPD peritonitis.[3],[4] Although they are rarely encountered, treatment of peritonitis cases due to Gram-negative microorganisms is more difficult.[5],[6] Suttonella indologenes is a microorganism of Cardiobacteriaceae family. It is an oxidase and indole-positive, catalase-negative, glucose and sucrose fermenting, and Gramnegative aerobic coccobacillus. Less is known about its biochemical structure, and it is characterized by 16S ribosomal RNA which consists of 1474 base pairs.[7] Its natural habitat is the mucous membranes of the upper respiratory tract.[8] There is limited number of case reports about fatal endocarditis caused by this microorganism due to infection in the prosthetic heart valves.[9],[10],[11],[12] However, there is no information on extracardiac involvement. This case report introduces a peritonitis picture caused by Suttonella indologenes in a patient receiving CAPD.

   Case Report Top

A 79-year-old male patient, who has been receiving CAPD for eight years due to diabetic nephropathy-associated chronic renal failure (CRF), presented to the emergency room with abdominal pain, high fever, and cloudy dialysate fluid. During history taking, it was found that patient had two exacerbations of peritonitis which required hospitalization. However, causative microorganism and applied antibiotic therapy information could not be obtained because the patient received treatment in another health-care center. Peritoneal dialysis (PD) solutions that the patient used were; PD4 Dianeal 1.36% 2000cc three times a day (t.i.d.), Extraneal 2000 mL once a day (q.d.). On his physical examination, blood pressure was 100/60 mm Hg and body temperature was 38.5°C. There was extensive abdominal tenderness, rebound, and muscular defense. Abdominal tomography was performed with initial diagnosis of acute abdomen. There were no pathological findings detected in tomography results other than free fluid. There was no prominent erythema, edema, and tenderness around the peritoneal catheter, and yet purulent discharge from the catheter exit site was not detected. Tunnel ultrasonography was performed. The fluid collection was not observed around the catheter. White blood cell count was 1800/mL, neutrophil count was 1400/mL, and C-reactive protein (CRP) was 218 mg/L in the peritoneal fluid obtained at presentation. The patient was considered to have acute peritonitis. Blood culture was performed, and empirical treatment of CAPD peritonitis was started with Cefazolin 2g/day and Gentamicin 80 mg/day, which were administered into the peritoneal dialysate fluid after obtaining peritoneal fluid specimens for microscopic examination and culture. Direct staining of the peritoneal fluid showed 8–10 Gram-negative coccobacilli in all microscopic fields. Suttonella indologenes was grown in the two separate peritoneal fluid cultures of the patient, who had neutrophil count of 2000/mL in the peritoneal fluid and no improvement in the clinical symptoms on the 3rd day of empirical therapy. Since Suttonella indologenes from Cardiobacteriaceae family was grown in peritoneal fluid, echocardiography was performed. Transthoracic echocardiography revealed preserved left ventricular systolic function, left ventricular hypertrophy, and mild aortic insufficiency. There was no any sign of infective endocarditis on transthoracic echocardiography.

There was no growth in the blood culture. Based on the results of antibiotic susceptibility test, antibiotherapy was modified as Ampicillin-Sulbactam 2 g/day and Gentamicin 80 mg/day. On the 3rd day of treatment modification (6th day of the peritonitis therapy), neutrophil count was 1000/mL, and CRP was 162 mg/L in the peritoneal fluid with no regression observed in the clinical symptoms of the patient. Because of unresponsiveness to the treatment, PD catheter was removed, and antibiotherapy was revised as IV imipenem/cilastatin 4 × 250 mg/ day. Antibiotic therapy was continued intravenously for seven days following removal of peritoneal catheter. However, antibiotics were applied for 14 days including the use that was started empirically on the first admission and the treatment given intraperitoneally. Suttonella indologenes was grown in PD catheter culture. Peritonitis symptoms of the patient improved after the removal of peritoneal catheter and CRP decreased to 46 mg/L. The patient was involved in the hemodialysis program.

   Discussion Top

Gram-positive bacteria such as Staphylococcus aureus, which is found in the normal flora of the skin, account for 60%–80% of the pathogens associated with CAPD peritonitis.[13] In addition, although rare, Gram-negative bacteria that are hardly controlled by antibiotic-therapy or that necessitate removal of peritoneal catheter because of unresponsiveness to treatment may also cause peritonitis.[14] Suttonella indologenes is a Gram-negative coccobacillus, the natural habitat of which is the mucous membranes of the upper respiratory tract.[8],[9] There have been the previous description of fatal prosthetic valve endocarditis attributes to Suttonella indologenesis.[10],[11],[12] The present case was a 79-year-old male patient who has been receiving CAPD for eight years for diabetic nephropathy-related CRF. Echocardiography was performed, but no pathological finding was determined that associated with endocarditis. No response was obtained to the empirical peritonitis therapy (Cefazolin + Gentamicin) which was started at the admission to hospital. After the growth of Suttonella indologenes in the dialysate fluid samples on the 3rd day of treatment, antibio-therapy (Ampicillin-Sulbactam + Gentamicin) compatible with antibiotic susceptibility test was started. However, the patient showed no clinical or laboratory response to the treatment during the follow-up period; thereby, peritoneal catheter was removed on the 6th day of treatment. PD catheter, as well as prosthetic heart valve, is made of synthetic materials.[15],[16] It could be suggested that Suttonella indologenes may cause severe infection pictures on the ground of synthetic materials found in the systems and Suttonella indologenes should be kept in mind as a source of infection in the patients with the history of such surgical interventions.

   Conclusion Top

Suttonella indologenes is a rarely encountered microorganism, which could lead to fatal endocarditis in the patients with prosthetic heart valve. The literature contains three endocarditis-related case reports;[10],[11],[12] however, there is no information that it causes peritonitis. The present case is the first case suggesting that Suttonella indologenes can lead to peritonitis in CAPD patients.

Conflict of interest: None declared.

   References Top

Cisse MM, Hamat I, Gueye S, et al. Peritonitis in patients on peritoneal dialysis: A single-center experience from dakar. Saudi J Kidney Dis Transpl 2012;23:1061-4.  Back to cited text no. 1
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Alwakeel JS, Alsuwaida A, Askar A, et al. Outcome and complications in peritoneal dialysis patients: A five-year single center experience. Saudi J Kidney Dis Transpl 2011; 22:245-51.  Back to cited text no. 2
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Vikrant S, Guleria RC, Kanga A, et al. Microbiological aspects of peritonitis in patients on continuous ambulatory peritoneal dialysis. Indian J Nephrol 2013;23:12-7.  Back to cited text no. 3
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Abu-Aisha H, Elhassan EA, Khamis AH, et al. Rates and causes of peritonitis in a national multicenter continuous ambulatory peritoneal dialysis program in sudan: First-year experience. Saudi J Kidney Dis Transpl 2007;18: 565-70.  Back to cited text no. 4
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Berbari N, Johnson DH, Cunha BA. Xanthomonas maltophilia peritonitis in a patient undergoing peritoneal dialysis. Heart Lung 1993;22:282-3.  Back to cited text no. 5
Szeto CC, Li PK, Leung CB, et al. Xanthomonas maltophilia peritonitis in uremic patients receiving continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1997;29: 91-5.  Back to cited text no. 6
Dewhirst FE, Paster BJ, La Fontaine S, Rood JI. Transfer of Kingella indologenes (Snell and lapage 1976) to the genus Suttonella gen. Nov. As Suttonella indologenes comb. Nov.; transfer of Bacteroides nodosus (Beveridge 1941) to the genus Dichelobacter gen. Nov. As Dichelobacter nodosus comb. Nov.; and assignment of the genera Cardiobacterium, Dichelobacter, and Suttonella to Cardiobacteriaceae fam. Nov. In the gamma division of Proteobacteria on the basis of 16S rRNA sequence comparisons. Int J Syst Bacteriol 1990;40:426-33.  Back to cited text no. 7
Patel NJ, Moore TL, Weiss TD, Zuckner J. Kingella kingae infectious arthritis: Case report and review of literature of Kingella and Moraxella infections. Arthritis Rheum 1983; 26:557-9.  Back to cited text no. 8
Henriksen SD, Bovre K. Moraxella kingii sp.nov. a haemolytic, saccharolytic species of the genus Moraxella. J Gen Microbiol 1968; 51:377-85.  Back to cited text no. 9
Jenny DB, Letendre PW, Iverson G. Endocarditis caused by Kingella indologenes. Rev Infect Dis 1987;9:787-9.  Back to cited text no. 10
Ozcan F, Yıldız A, Ozlü MF, et al. A case of fatal endocarditis due to Suttonella indologenes. Anadolu Kardiyol Derg 2011;11:85-7.  Back to cited text no. 11
Yang EH, Poon K, Pillutla P, Budoff MJ, Chung J. Pulmonary embolus caused by Suttonella indologenes prosthetic endocarditis in a pulmonary homograft. J Am Soc Echocardiogr 2011;24:592.e1-3.  Back to cited text no. 12
Al-Hwiesh AK, Abdul Rahman IS. Prevention of staphylococcal peritonitis in CAPD patients combining ablution and mupirocin. Saudi J Kidney Dis Transpl 2008;19:737-45.  Back to cited text no. 13
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Prasad N, Gupta A, Sharma RK, et al. Outcome of gram-positive and gram-negative peritonitis in patients on continuous ambulatory peritoneal dialysis: A single-center experience. Perit Dial Int 2003;23 Suppl 2:S144-7.   Back to cited text no. 14
15. El-Shahat YI, Cruz C. The impact of catheter design on preventing CAPD complications. Saudi J Kidney Dis Transpl 1995;6:275-9.  Back to cited text no. 15
Khandelwal M, Bailey S, Izatt S, et al. Structural changes in silicon rubber peritoneal dialysis catheters in patients using mupirocin at the exit site. Int J Artif Organs 2003;26:913-7.  Back to cited text no. 16

Correspondence Address:
Dr. Nurhayat Ozkan Sevencan
Department of Internal Medicine, Faculty of Medicine, Karabuk University, Sirinevler, 78600, Karabuk
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DOI: 10.4103/1319-2442.225200

PMID: 29456228

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