Year : 2008 | Volume
: 19 | Issue : 3 | Page : 428--430
Brucella Peritonitis in a Patient on Peritoneal Dialysis
Adel Alothman, Abdulrahman Al Khurmi, Sadoon Al Sadoon, Fayez AlHejaili
Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
Department of Medicine, Mail Code 1443, King Abdulaziz Medical City, Riyadh
Brucellosis is endemic in Saudi Arabia. Brucella peritonitis is an uncommon clinical condition. We herewith report a 67-year-old man with chronic renal failure on continuous ambulatory peritoneal dialysis (CAPD) for four months, who developed chronic brucella peritonitis. Peritoneal fluid grew brucella species with positive brucella serology.
|How to cite this article:|
Alothman A, Al Khurmi A, Al Sadoon S, AlHejaili F. Brucella Peritonitis in a Patient on Peritoneal Dialysis.Saudi J Kidney Dis Transpl 2008;19:428-430
|How to cite this URL:|
Alothman A, Al Khurmi A, Al Sadoon S, AlHejaili F. Brucella Peritonitis in a Patient on Peritoneal Dialysis. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2023 Jan 29 ];19:428-430
Available from: https://www.sjkdt.org/text.asp?2008/19/3/428/40504
Infection with the Brucella species is a systemic disease. Brucellosis is a zoonotic disease and remains endemic worldwide. ,, The clinical presentation of brucellosis can be polymorphic, which can cause a delay in making the correct diagnosis.  The mode of transmission of brucella organisms to humans is usually by direct contact with contaminated animals, ingestion of infected dairy products and inhalation of infectious aerosols. ,
The clinical manifestations of brucellosis are variable; however, it was found that brucella peritonitis is a rare entity, particularly in the Arabian peninsula. ,,,, The presence of a foreign body within the peritoneal cavity has been considered a risk factor to develop bacterial peritonitis, including infection with the brucella species. ,
Saudi Arabia is known to be endemic for brucellosis with the reported incidence in 2002 being 21 cases per 100,000 per year, which had actually dropped from 86 cases per 100,000 per year during early 1990. , We report a case of brucella peritonitis in a patient on continuous ambulatory peritoneal dialysis (CAPD); to the best of our knowledge, this appears to be the third such case in medical literature.
A 67-year-old man with end-stage renal disease (ESRD) on CAPD for four months presented with change of peritoneal fluid color, associated with abdominal pain and increased lower limb edema of one weeks' duration. There was a history of raw milk ingestion. There was no history of chest symptoms, fever or rigors. Past medical history was positive for hypertension and benign prostatic hypertrophy.
On physical examination, the patient was afebrile with normal vital signs. Chest and cardiovascular examination was normal. Abdominal examination revealed diffuse mild tenderness with clean CAPD catheter exit-site. There was bilateral lower limb edema.
Laboratory tests showed white blood cell (WBC) count of 8.1 x 10 9 cells/L, hemoglobin of 82 g/L and platelet count of 137,000/mm 3 . The serum creatinine was 293 µmol/L, blood urea was 12 mmol/L, alanine transaminase was 13 IU/L and electrolytes were normal. The erythrocyte sedimentation rate (ESR) was 63 mm/hr.
Analysis of the peritoneal fluid showed cloudy appearance, WBC count was 3356 cells/mm 3 with 8% lymphocytes and 85% neutrophils; the red blood cell count was 4 cells/mm 3 . Gram's stain did not show any organisms.
The patient was admitted to the hospital with a diagnosis of bacterial peritonitis and was started on cefazolin 1.0g given intraperitoneally once daily. The patient improved clinically and peritoneal fluid analysis repeated on the fourth day of admission showed clear appearance, WBC count of 11 cells/mm 3 , including 62% lymphocytes and 12% neutrophils.
The patient was discharged and reviewed after two weeks in the clinic at which time he was asymptomatic. Peritoneal fluid culture grew brucella species on day six after culture. Serology titer for Brucella melitensis was 1:2560, and for Brucella abortus, it was 1:640.
The patient was then started on doxycycline 100 mg and rifampicin 600 mg given orally once daily; the two drugs were given for a total duration of two months after presentation. Serology for Brucella melitensis was 1:5120, and for Brucella abortus, it was 1:2560. The peritoneal dialysis catheter was removed and patient was shifted to hemodialysis. The patient was maintained on doxycylcine and rifampin for the next 12 weeks. Brucella serology at this point of time was 1:2560 for Brucella melitensis and 1:1280 for Brucella abortus. The patient remained asymptomatic and treat-ment was stopped. One-year later, brucella serology was 1:1280 for Brucella melitensis and 1:320 for Brucella abortus.
Brucella peritonitis appears to be an uncommon disease, even in places where brucellosis is endemic. ,,,,,, In one study, generalized brucellosis was found in 96.2%, pneumonia in 1.3%, epididymo-orchitis in 1.3%, abortion in 0.6%, and threatened abortion in 0.6%.  It appears that seeding of brucella organisms to the peritoneal tissue is a very rare occurrence. 
A review of the medical literature revealed that most of the patients with brucella peritonitis were reported from Turkey. ,,,,, It is likely that this is due a high degree of awareness of brucellosis in Turkey. Patients with brucella peritonitis had certain predisposing factors like chronic liver disease, ,,,, presence of ventriculoperitoneal shunts, [,16] presence of CAPD catheter. , or some unknown risks factors. ,, Our patient developed chronic brucella peritonitis unlike the patient reported by Taskapan et al.  The risk factor was the presence of peritoneal dialysis catheter, and its removal helped in eradication of brucella organisms.
We recommend that patients on CAPD should have the peritoneal dialysis catheter removed once the diagnosis of brucella peritonitis is made. Also, such patients should be on anti-brucella medication for 6-8 weeks.
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