Mycobacterial peritonitis: difference between non-tuberculous mycobacteria and Mycobacterium tuberculosis

Unlike tuberculous peritonitis, peritonitis due to non-tuberculous mycobacteria (NTM) has unclear clinical manifestations. This study aimed to clarify the clinical manifestations and laboratory results of NTM peritonitis and compare it to tuberculous peritonitis. This retrospective study was conducted from 2000 to 2008 in a medical centre in Taiwan. Patients with mycobacteria isolated from ascites were identified and compared according to causative pathogens (Mycobacterium tuberculosis or NTM). Those with NTM peritonitis were further classified into the ‘probable’ and ‘possible’ groups based on diagnostic evidence. Twenty-five patients with NTM peritonitis and 65 with tuberculous peritonitis were reviewed. Mycobacterium avium complex was the most common NTM pathogen (52%). There was no obvious difference between the ‘probable’ and ‘possible’ NTM peritonitis groups regarding age and laboratory data. Patients with NTM peritonitis and those with tuberculous peritonitis had no differences in age or gender but varied in symptoms and serum laboratory data. NTM peritonitis was 100% associated with underlying co-morbidities and had lower proportions of lymphocytes and albumin level in ascites. Twelve (48%) NTM peritonitis and 21 (32%) tuberculous peritonitis patients died during the 6-month follow-up. Antimycobacterial treatment, but not mycobacterial species, was correlated with better 6-month survival. In Taiwan, NTM is responsible for 28% of mycobacterial peritonitis cases, which have a poor prognosis if untreated. There are some differences in clinical manifestations between NTM and tuberculous peritonitis. NTM peritonitis should be considered in patients with peritonitis but without causative microorganisms identified other than NTM.     

结核性腹膜炎诊断技术的研究进展

结核性腹膜炎在现代临床上属于重要结核疾病,因其临床表现缺乏特异性,以致目前仍为临床中较难诊断的一种结核疾病,更对结核性腹膜炎的及时有效治疗造成较严重困难,因此近几年结核性腹膜炎诊断技术一直是结核病诊治的攻克课题。现笔者在本文中对结核性腹膜炎诊断技术的研发应用进展进行统一综述,归纳各项结核性腹膜炎诊断技术的优点与欠缺之处。     

Roles of Neutrophil Gelatinase-Associated Lipocalin in Continuous Ambulatory Peritoneal Dialysis-Related Peritonitis

Introduction  We measured the neutrophil gelatinase-associated lipocalin (NGAL) concentration in peritoneal dialysate effluent (PDE) collected following an acute episode of continuous ambulatory peritoneal dialysis (CAPD)-related peritonitis. Results  NGAL concentration in PDE increased in the first 3 days after developing peritonitis and correlated well with the neutrophil count. In patients with culture-negative peritonitis, the NGAL in PDE was lower than that in patients with gram-positive or gram-negative peritonitis. Apart from providing additional diagnostic support to bacterial-induced peritonitis, measurement of NGAL in PDE may be useful to differentiate the neutrophil-dependent culture-negative peritonitis from that associated with non-bacterial or non-cellular etiologies. Conclusion  Human peritoneal mesothelial cell (HPMC) is another source of NGAL during peritonitis. NGAL was specifically induced in HPMC by IL-1β. Incubation of HPMC with recombinant NGAL reversed the transforming growth factor-β-induced up-regulation of Snail and vimentin but rescued the down-regulation of E-cadherin. Our data suggest that NGAL may exert a protective effect in modulating the epithelial-to-mesenchymal transition activated following peritonitis.     

Peritonitis by fish bone. Review of the literature. Pathogenic discussion

From one case of peritonitis by fish bone, we have reviewed medical literature in order to explain the mechanism of this type of peritonitis perforation, which can be assimilated to peritonitis in three phases.     

Spontaneous cryptococcal peritonitis in cirrhotic patients

Spontaneous bacterial peritonitis is a common complication in patients with cirrhosis and ascites. However, spontaneous peritonitis caused by Cryptococcus neoformans is uncommon. Delayed diagnosis of cryptococcal peritonitis often results in death. We describe three cases of spontaneous cryptococcal peritonitis in patients with decompensated cirrhosis. One case had associated symptomatic human immunodeficiency virus infection. Clinical awareness of this entity may lead to the early diagnosis and proper treatment.     

Laboratory indices of clinical peritonitis: total leukocyte count, microscopy, and microbiologic culture of peritoneal dialysis effluent.

Total leukocyte count, microscopy, and conventional bacteriologic culture (10-ml sediment) of dialysis effluent were assessed for their ability to detect peritonitis in patients on peritoneal dialysis. A total of 73 patients were surveyed over a 17-month period. Laboratory findings included an examination of 1,774 dialysate samples and culture results from blood, wounds, indwelling catheters, and other specimens. Of 90 peritonitis events, 72 were culture positive. Gram-stained films were positive in no more than 14% of the dialysates collected during periods of clinical peritonitis. Factors which adversely affected the microscopic or cultural detection of microorganisms in effluent included the concentration of organisms in dialysate, antibiotic therapy, and growth medium used. Seeding of the peritoneum with organisms originating from other sites of infection or colonization was documented, although infrequent, yet bacteremia secondary to peritonitis was not seen. Because of the frequent isolation of microorganisms from dialysates in the absence of clinical peritonitis, culture-positive findings were a poor predictor of peritonitis without other evidence of infection. Detection of peritonitis by total leukocyte count (without a differential count) of dialysate specimens was adversely affected by the overlap in cell counts between dialysates collected either during or in the absence of peritonitis. This was attributed in part to nonspecific increases in dialysate cell count in the absence of peritonitis and was associated with intermittent dialysis and extraperitoneal infection.     

Origin of calcification in healed meconium peritonitis

Calcification is the most characteristic pathologic feature of healed meconium peritonitis. Occurrence of calcification in meconium peritonitis has been reported, but its mechanism has not been discussed. According to our studies, the cause of calcification and giant cell reaction is meconium peritonitis is related to several distinct factors leading to three morphologic presentations described under type I, II and III in this paper. These factors can be traced to components of meconium. These morphologic findings are specific and in the proper context diagnostic of meconium peritonitis.     

Postoperative laparoscopic treatment of diffuse suppurative peritonitis

The role of prolonged postoperative abdominal treatment through surgical laparoscope and a special cannula as part of combined treatment for generalized purulent peritonitis is considered. High mean-molecular toxicity of peritoneal exudation is demonstrated in peritonitis. Recommendations are made on the use of laparoscopic treatment in patients with peritonitis.     

Fungal peritonitis in peritoneal dialysis patients: effect of fluconazole treatment and use of the twin-bag disconnect system.

Fungal peritonitis is an uncommon but potentially life-threatening complication for patients undergoing continuous ambulatory peritoneal dialysis. This retrospective study evaluated the efficacy of fluconazole in fungal peritonitis treatment and the incidence of fungal peritonitis in different peritoneal dialysis disconnect systems. Fungal peritonitis was caused by Candida species in 67% of episodes. The most common pathogen in this series was Candida parapsilosis (29%), followed by Candida albicans (14%). One patient (5%) died within 1 month after admission for treatment of fungal peritonitis. Only 1 patient (5%) in this series could resume peritoneal dialysis. Treatment with fluconazole alone has an effect comparable to intraperitoneal (IP) amphotericin B alone or IP amphotericin B combined with oral or intravenous fluconazole. The incidence of fungal peritonitis in patients who used the spike, Y-set, and UV antiseptic systems was 5.69, 6.20, and 2.93 times, respectively, as frequent as that of fungal peritonitis in patients who used the twin-bag disconnect system.     

Corynebacterium group JK peritonitis in patients on continuous ambulatory peritoneal dialysis

Summary Corynebacterium group JK is described as the aetiologic agent of a second episode of peritonitis which occurred after a period of antibiotic treatment for likely endogenous peritonitis. Inclusion of vancomycin is suggested for treatment of continuous ambulatory peritoneal dialysis (CAPD) peritonitis in patients colonized by these multiresistant bacteria.     

Pseudomonas sp. group Ve-2 bacterial peritonitis in a patient on continuous ambulatory peritoneal dialysis.

Pseudomonas sp. group Ve-2 peritonitis occurred in a patient on continuous ambulatory peritoneal dialysis who had recently completed intraperitoneal cephalosporin therapy for culture-negative peritonitis. This is the second reported case of peritonitis in this population of patients due to this unusual organism, which is usually resistant to most cephalosporin antibiotics.     

Microbiology of peritoneal dialysis-related infection and factors of refractory peritoneal dialysis related peritonitis: A ten-year single-center study in Taiwan

BackgroundPeritoneal dialysis (PD)-related infection is a serious complication of patients with PD. Refractory peritonitis may lead to failure of PD, shift to hemodialysis (HD) or death. Besides, microbiologic resistance increased worldwide that might impact the treatment choice for such infections. Investigating the causative pathogens and risk factors of PD-related infections in Taiwan was warranted.MethodsThis is a retrospective study involving patients with PD from 2007 to 2016 in a southern Taiwan hospital. Patient characteristics, microbiological data, outcomes, and factors associated with refractory peritonitis were analyzed.ResultsThere were 190 episodes of PD-related peritonitis in 110 patients from this cohort. Gram-positive organisms were the leading cause of PD-related peritonitis, but gram-negative organisms, esp. Pseudomonas aeruginosa, were predominant for exit site infection and tunnel infection. The incidence of peritonitis was 0.25 episode per patient-year (1 episode per 47.69 months). The refractory rate was 14.2% (27/190). Methicillin resistance was noted in 2 (13.3%) of 15 Staphylococcus aureus isolates. Of 114 isolates, 72.8% (83) were susceptible to either cefazolin or gentamicin. Staphylococcus spp. and Escherichia coli infections were significantly associated with refractory peritonitis. Baseline hyponatremia (<130 mmol/L) was independently associated with refractory peritonitis.ConclusionGram-positive organisms remained major cause of PD-related peritonitis. About three quarters of causative pathogens were susceptible to the recommended empirical treatment for PD-related peritonitis. Baseline hyponatremia (<130 mmol/L) was independently associated with refractory peritonitis. Staphylococcus spp. and E. coli infections had important roles for refractory peritonitis.     

HBO in the combined therapy of purulent peritonitis and peritoneal sepsis

The study was made of HBO effect on changes of biologic fluid toxicity in purulent peritonitis. HBO was introduced in combined therapy of 68 patients (32 with general peritonitis and 36 with peritoneal sepsis). Lethality in peritonitis patients reached 40.6% (19 patients), in sepsis patients 33.3% (12 patients).     

Secondary Aeromonas peritonitis is associated with polymicrobial ascites culture and absence of liver cirrhosis compared to primary Aeromonas peritonitis

Aeromonas peritonitis remains a rare condition. In this study we describe the clinical features of primary and secondary Aeromonas peritonitis, and compare the differences between these two diseases entities. Patients with Aeromonas peritonitis were identified from microbiological and medical records during the period between March 1994 and March 2003. Clinical characteristics, laboratory data, microbiological results, treatment and outcome of patients were obtained by retrospective chart review. 22 and 27 patients with primary or secondary peritonitis caused by Aeromonas species were identified. All except two of these patients were adults, with a median age of 62.4 (31-76) vs 65.8 (8-85) years, respectively. Males were predominant (82 vs 78%). Peritonitis was community acquired in 73% and 56% of patients in these two groups, respectively. Significantly higher prevalence of underlying liver cirrhosis (96 vs 7%, p<0.001), which was Child-Pugh class C in 91% of cases, in primary peritonitis was noted. Primary peritonitis was more likely to be monomicrobial (100 vs 15%, p<0.001) and complicated by bacteremia (50 vs 7%, p=0.011). A source of intraabdominal infection should be sought when Aeromonas peritonitis occurs in a patient who has no history of liver cirrhosis or who has a polymicrobial result of ascites culture.     

Influence of nutritional status on CAPD peritonitis

To investigate the effect of nutritional status of continuous ambulatory peritoneal dialysis (CAPD) patients on the development of peritonitis, a cross-sectional study of the nutritional status of 79 CAPD patients and a retrospective study on the incidence of peritonitis in these patients were done. The incidences of peritonitis were compared according to the nutritional status of these patients on CAPD. Protein-caloric malnutrition assessed by a score system based on triceps skinfold thickness, mid-arm circumference, serum albumin level and relative body weight was demonstrated in 27 patients (34%) among 79 total CAPD patients. The incidence of peritonitis was significantly higher in poor nutritional status patients, with 1.09 +/- 0.86/patient-year, than that in normal nutritional status patients with 0.64 +/- 0.72/patient-year (p less than 0.05). In patients with the same nutritional status, patients using Dianeal solution had a trend of a lower incidence of peritonitis than those using Peritosol solution. In conclusion, the nutritional status and possibly the type of CAPD solution may influence CAPD peritonitis as risk factors.     

Simple peritoneal sclerosis and sclerosing peritonitis: related or distinct entities?

AIM: The etiopathogenesis of sclerosing peritonitis is still debated, with some sustaining that it is a rare form of progression of simple peritoneal sclerosis and others that it is a primitive form. The aim of the present research was to clarify this question. MATERIAL AND METHODS: 438 peritoneal biopsies from 253 patients were re-examined. 174 were obtained prior to peritoneal dialysis and 224 after various periods of dialysis. Forty biopsies were from peritoneal dialysis patients who developed sclerosing peritonitis. Peritoneal morphology was studied for signs of transition from simple sclerosis to sclerosing peritonitis. RESULTS: Evidence was found sustaining the hypothesis that simple sclerosis to sclerosing peritonitis patients have distinct pathologies. CONCLUSIONS: The results confirm previous observations, excluding the existence of any type of relation between simple peritoneal sclerosis to sclerosing peritonitis.     

Dialysis catheter infection related peritonitis: incidence and time dependent risk

The aim of this study was to conduct an in-depth analysis of the relationship of exit site and tunnel infection (ES/TI) to peritonitis and catheter loss in peritoneal dialysis patients, with emphasis on the incidence and risk of infection over time. Bacterial epidemiologies of 63 consecutively implanted catheters were studied for a combined total of 1,248 dialysis months. Analyses of bacterial profiles, infection rates, probabilities of time to first infection, and catheter survival were performed. The probability of first ES/TI and peritonitis was greatest during the first postimplant year. The earlier in dialysis history that patients developed an infection, the more infection prone they continued to be during the course of their dialysis experience. Staphylococcus aureus was the predominant organism for both ES/TI and peritonitis. The incidence of S. aureus infection was greatest during the first year and decreased over time on dialysis. S. aureus ES/TI caused significant risk for subsequent development of peritonitis, and 93% of ES/TI related peritonitis episodes were caused by this organism. Half of all ES/TIs that led to related peritonitis occurred by 3.5 months, and 100% by 12.8 months postimplant. S. aureus ES/TI related peritonitis led to catheter loss in 85% of cases. Our study identified a high risk period for infection for as long as 12 months postimplant. The inherent characteristics of ES/TI related peritonitis suggest that prevention should focus on both the organism and time period at risk. These findings are important in considering issues regarding S. aureus prophylaxis regimens versus nasal carrier treatment protocols.     

THE RISK FACTORS AND OUTCOME OF FUNGAL PERITONITIS IN CONTINUOUS AMBULATORY PERITONEAL DIALYSIS PATIENTS

Aim: To determine the risk factors and outcome of fungal peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients over a 7-year period. Patients and Methods: This retrospective study was conducted on 30 cases of fungal peritonitis in CAPD patients during a 7-year period (2000–2007). The diagnosis was based on elevated CAPD effluent count and isolation of fungi. Patients were evaluated for previous episode of bacterial peritonitis. Results: The incidence of fungal peritonitis was 16.2%. Age varied between 8 and 75 years, with a mean age of 57 years. Twenty-three were males (76.7%) and seven were females (23.3%). Seventeen patients (56.6%) had previous episodes of bacterial peritonitis that was treated with multiple antibiotics. The common fungus was Candida species (50%). CAPD catheter removal and initiation of antifungal therapy was done for all patients. Reinsertion was done for three (10%) patients. Mortality rate was 20%. Conclusion: Patients with previous bacterial peritonitis and antibiotic usage are at greater risk of developing fungal peritonitis.     

Peritonitis due to Curvularia inaequalis in an elderly patient undergoing peritoneal dialysis and a review of six cases of peritonitis associated with other Curvularia spp

Fungal peritonitis due to Curvularia species in patients undergoing peritoneal dialysis is a very rare problem. We report a case of peritonitis caused by Curvularia inaequalis. This is the first report in the English literature of this species causing human infection. We also review the six previously reported cases of continuous ambulatory peritoneal dialysis peritonitis caused by other Curvularia species.     

The importance of mesenteric vascular insufficiency in meconium peritonitis

The etiology of bowel perforations leading to meconium peritonitis was investigated in an attempt to explain the occurrence of such perforations in the absence of primary intestinal obstruction. Bowel specimens from 22 patients who had presented with meconium peritonitis during a 15-year period, as well as specimens from five patients with intestinal atresia without associated meconium peritonitis, were re-evaluated microscopically. An extensive review of the literature concerning meconium peritonitis, involving 1,084 patients, was compared with the results of a retrospective study of 69 patients from The Netherlands. In approximately 50 per cent of these cases there was no detectable primary cause of the bowel perforation. The pathologic findings, in combination with earlier experimental studies, indicate that vascular insufficiency may result in bowel wall perforation without prior intestinal obstruction. It is suggested that temporary decrease of mesenteric blood flow could lead to intestinal atresia and/or meconium peritonitis.