Peritonitis is the most frequent complication of peritoneal dialysis. Diagnosis of peritonitis includes symptoms and signs of peritonitis with a cloudy aspirate of more than 100 WBC/ml, as well as positive cultures. Although sterile peritonitis has been reported in the literature, to the best of our knowledge this is the first report of an unusual presentation of peritonitis without any white blood cells in the peritoneal aspirate despite multiple positive peritoneal cultures.
An 82-year-old Caucasian man who had been on continuous cycling peritoneal dialysis for 12 years was admitted to our hospital with general malaise, loss of appetite, weight loss and somnolence. He did not describe abdominal pain or fever. Even though his peritoneal fluid was consistently negative for leukocytes and clear, he had peritonitis with different organisms consecutively.
Our case report shows that any patient on peritoneal dialysis presenting with evidence of infection (fever, peripheral leukocytosis) without an obvious cause should have aspirate cultures done even if the aspirate is clear and abdominal pain is absent. Our case report may change the initial work-up and management of these patients. We believe this report is of interest to general medicine and emergency room physicians as well as nephrologists.
•We present three different and well-described cases of severe GAS peritonitis.•We give a review of current literature.•We highlight the difficulties in treatment and diagnostics.
Acute primary peritonitis due to group A Streptococci (GAS) is a rare but life-threatening infection. Unlike other forms of primary peritonitis it affects predominantly young previously healthy individuals and thus is often confused with the more frequent secondary peritonitis. A case series of three patients is presented as well as a review of the literature focusing on pitfalls in the diagnose and therapy of GAS peritonitis.
A retrospective analysis of three patients with primary GAS peritonitis was performed. Furthermore a systematic review of all cases of primary GAS peritonitis published from 1990 to 2013 was performed comparing demographics and clinical presentation, as well as radiological imaging, treatment and outcome.
All three female patients presented initially with high fever, nausea and severe abdominal pain. Radiological imaging revealed intraperitoneal fluid collections of various degrees, but no underlying cause of peritonitis. Broad antibiotic treatment was started and surgical exploration was performed for acute abdomen in all three cases. Intraoperatively fibrinous peritonitis was observed, but the correct diagnosis was not made until microbiological analysis confirmed GAS peritonitis. One patient died within 24 h after admission. The other two patients recovered after multiple surgeries and several weeks on the intensive care unit due to multiple organ dysfunction syndrome. The fulminant clinical course of the three patients resembled those of many of the published cases: flu-like symptoms, high fever, severe acute abdominal pain and fibrinous peritonitis without obvious infectious focus were the most common symptoms reported in the literature.
GAS primary peritonitis should be considered in particular in young, previously healthy women who present with peritonitis but lack radiological findings of an infectious focus. The treatment of choice is immediate antibiotic therapy. Surgical intervention is difficult to avoid, since the diagnosis of GAS peritonitis is usually not confirmed until other causes of secondary peritonitis have been excluded.
GAS, group A β-hemolytic Streptococci; ICU, intensive care unit; Peritonitis; Group A Streptococcus; abdominal pain; acute abdomen
We report the case of a 24-year-old male patient admitted for recent ascites and splenomegaly of unknown origin. The patient was referred to our institution with complaints of diarrhea, epigastric pain, abdominal cramping and weight loss over the past three weeks. The acute onset presented with colicky abdominal pain and peritoneal effusion. History revealed reduced appetite and weight gain of 7 kg over the last one month. His past medical history and family history was negative. He had no history of alcohol abuse or viral hepatitis infection. Laboratory data revealed normal transaminases and bilirubin levels, and alkaline phosphatase and gammaglutamyltransferase were within normal range. A diagnostic laparoscopy was performed which showed free peritoneal fluid and normal abdominal viscera. Upper gastrointestinal system endoscopy performed a few days later revealed diffuse severe erythematous pangastritis and gastroduodenal gastric reflux. Duodenal biopsies showed chronic nonspecific duodenitis. Antrum and corpus biopsies showed chronic gastritis. The ascitic fluid was straw-colored and sterile with 80% eosinophils. Stool exam was negative for parasitic infection. Treatment with albendazole 400 mg twice daily for 5 days led to the disappearance of ascites and other signs and symptoms. Three months after albendazole treatment the eosinophilic cell count was normal. The final diagnosis was consistent with parasitic infection while the clinical, sonographic and histological findings suggested an eosinophilic ascites. We emphasize the importance of excluding parasitic infection in all patients with eosinophilic ascites. We chose an alternative way (albendazole treatment) to resolve this clinical picture. With our alternative way for excluding this parasitic infection, we treated the patient and then found the cause.
Eosinophilic ascites; Parasitic infection; Albendazole
The number of cases of tuberculosis as a complication in people with immunodeficiency, people on immunosuppressive therapy and among the immigrant population is increasing in Germany. However, tuberculous peritonitis rarely occurs without these risks, particularly in Germans. The incidence of tuberculous peritonitis in Germany is very low; tuberculosis of the intestinal tract was found in approximately 0.8 % of tuberculosis cases in 2004. The diagnosis of tuberculous peritonitis is often delayed on account of non-specific clinical symptoms. The absence of specific biological markers, long incubation times for cultures and non-specific radiographic or ultrasonographic signs increase the morbidity associated with this treatable condition.
We report a case of tuberculous peritonitis in a 73-year-old female German patient. Her medical history revealed primary biliary cirrhosis (PBC) since 1992. On admission, she complained of abdominal pain, vomiting, ascites and peripheral edema. The patient has been in a seriously reduced general condition and had fever up to 39.6°C. A few weeks earlier, the patient was in another hospital with the same complaint. Inflammatory parameters were elevated, but the procalcitonin level was normal. Blood culture was always negative, as was the tuberculin test. Ultrasonography of the abdomen showed massive ascites with multiple septa. The patient underwent a computed tomography (CT) scan of the abdomen which showed a thickened intestinal wall in the sigmoid colon and a pronounced enhancement of the peritoneum. Computed tomography scans of the lung showed only slight bilateral pleural effusion. Because of the anaesthetic and bleeding risk due to thrombocytopenia, laparoscopy was not immediately undertaken. The culture from ascites was positive for M.tuberculosis after three weeks.
In primary biliary cirrhosis patients with non-specific clinical symptoms, such as vomiting, abdominal pain, ascites, weight loss, and fever, tuberculous peritonitis must be considered in the initial differential diagnosis, although these symptoms may be attributed to cirrhosis of the liver with spontaneous bacterial peritonitis. Ultrasonographic and CT scab findings are not specific for tuberculous peritonitis, but an awareness of the ultrasonographic features and the features of the CT scan may help in the diagnosis of tuberculous peritonitis and avoid clinical mismanagement.
Presentations of abdominal pain in patients on peritoneal dialysis deserve maximal attention and careful differential diagnosis on admittance to medical care. In this case report a gangrenous appendicitis in a patient on automated peritoneal dialysis is presented.
We report the case of a 38-year-old Caucasian man with end-stage renal disease who was on automated peritoneal dialysis and developed acute abdominal pain and cloudy peritoneal dialysate. Negative microbiological cultures of the peritoneal dialysis fluid and an abdominal ultrasonography misleadingly led to a diagnosis of culture negative peritonitis. It was decided to remove the peritoneal catheter but the clinical situation of the patient did not improve. An explorative laparotomy was then carried out; diffuse peritonitis and gangrenous appendicitis were found. An appendectomy was performed. Myocardial infarction and sepsis developed, and the outcome was fatal.
A peritoneal dialysis patient with abdominal pain that persists for more than 48 hours after the usual antibiotic protocol for peritoneal dialysis-related peritonitis should immediately alert the physician to the possibility of peritonitis caused by intra-abdominal pathology. Not only peritoneal catheter removal is indicated in patients whose clinical features worsen or fail to resolve with the established intra-peritoneal antibiotic therapy but, after 72 hours, an early laparoscopy should be done and in a case of correct indication (intra-abdominal pathology) an early explorative laparotomy.
Abdominal pain; Appendicitis; Myocardial infarction; Peritoneal dialysis
Tuberculosis is a major health problem worldwide. Sudan has high burden of tuberculosis (TB) with a prevalence of 209 cases per 100,000 of the population and it is commonly presented with pulmonary disease but involvement of the gastrointestinal tract is not uncommon. Abdominal tuberculosis comprises about 1–3 % of all cases of tuberculosis and about 12% of extrapulmonary tuberculosis. It involves the ileocecal region, but involvement of stomach and duodenum are rare sites. Here we present an unusual case of gastric outlet obstruction due to gastric tuberculosis.
A 54-year-old Sudanese man presented with a non-bile stain persistent projectile vomiting, and epigastric pain for two years associated with marked loss of weight. There is no fever or cough. He was on antacid, physical examination showed BMI 18 and stable vital signs. He was not pale or jaundiced, there was no cervical lymphadenopathy and chest was clear. Abdominal examination was normal apart of positive succussion splash. The results of haematological tests were normal, ESR was 30 mm/hr, hepatitis B, C and HIV were negative. Upper gastrointestinal endoscopy showed that the stomach was full of fluid and food particles and ulcerated mass in the pylorus extended to the proximal part of the duodenum with severe narrowing of the pylorus. The lesion biopsied and the result revealed active inflammatory cells, cryptitis and multiple lymphoid follicles, no malignancy seen. Sonographic test showed hypodense pyloric mass, enlarged para-aortic and mesenteric lymph nodes and mild pelvic ascites. A computed tomography scan of the abdomen and pelvis showed antral hypodense lesions multiple mesenteric lymphadenopathies peritoneal thickening and ascites. Chest X-ray was normal. Intra-operative findings were dilated stomach and pylorus mass with multiple mesenteric lymph nodes, peritoneal and omental seedlings all over with small nodules on the surface of the liver, gastro-jejunostomy was done. Histopathology confirmed the diagnosis of abdominal tuberculosis. Postoperative event was uneventful. Patient received anti-tuberculous.
Here we presented an unusual case of gastric outlet obstruction due to primary gastric tuberculosis, patient underwent surgery to relief his symptoms and received anti-tuberculous.
Abdominal tuberculosis; Gastric outlet obstruction; Gastric tuberculosis
Ascites is defined as the pathological accumulation of fluid in the peritoneal cavity. It is the most common complication of cirrhosis, which is also the most common cause of ascites. Viscosity is a measure of the resistance of a fluid to deform under shear stress. Plasma viscosity is influenced by the concentration of plasma proteins and lipoproteins, with the major contribution from fibrinogen. To our knowledge, the viscosity of ascitic fluid has not yet been studied.
To evaluate the role of ascitic fluid viscosity in discriminating between ascites due to portal hypertension-related and nonportal hypertension-related causes, and to compare results with the serum-ascites albumin gradient (SAAG).
The present study involved 142 patients with ascites presenting with diverse medical problems. Serum total protein, albumin, glucose, lactate dehydrogenase (LDH) levels and complete blood count were obtained for all subjects. Paracentesis was performed routinely on admission and all ascitic fluid samples were evaluated by manual cell count with differential, ascitic fluid culture and biochemistry (total protein, albumin, glucose and LDH). Cultures of ascitic fluid were performed at bedside in all patients using blood culture bottles. Ascitic fluid viscosity was measured in a commercially available cone and plate viscometer.
Of the 142 patients studied, 34 (24%) had an SAAG of 11 g/L or less, whereas 108 (76%) had an SAAG of greater than 11 g/L. Sex and mean age did not differ significantly between the two groups (P>0.05). Serum total protein, albumin, glucose, LDH levels, leukocyte count, ascitic fluid glucose levels and ascitic fluid leukocyte counts were similar in both groups, with no statistically significant relationship detected (P>0.05). However, the mean (±SD) ascitic fluid total protein (0.0172±0.1104 g/L versus 0.043±0.011 g/L), albumin (0.0104±0.0064 g/L versus 0.0276±0.0069 g/L) and LDH (102.76±80.95 U/L versus 885.71±199.93 U/L) were found to be higher in patients with an SAAG of 11 g/L or less than in those with an SAAG of greater than 11 g/L (P<0.001). The mean ascitic fluid viscosities were 0.86±0.12 centipoise (cP) and 1.22±0.25 cP in patients with an SAAG greater than 11 g/L and an SAAG of 11 g/L or less, respectively (P<0.001). Although ascitic fluid infection was detected in 35 patients (24.6%) (19 patients with spontaneous bacterial peritonitis, seven patients with culture-negative neutrocytic ascites, three patients with monobacterial non-neutrocytic bacterascites and six patients with secondary bacterial peritonitis), no significant effect on ascitic fluid viscosity was detected. Multiple linear regression analysis revealed that ascitic fluid total protein, albumin and LDH levels were independent predictors of ascitic fluid viscosity (P<0.001). The sensitivity, specificity, and positive and negative predictive values of ascitic fluid viscosity for the discrimination between ascites due to portal hypertension-related and nonportal hypertension-related causes according to the SAAG were determined by receiver operating characteristic analysis. Regarding the cut-off value of 1.03 cP, ascitic fluid viscosity measurement had a high sensitivity, specificity (98% and 80%, respectively), and positive and negative predictive value (79% and 94%, respectively) for the etiological discrimination of ascites.
The measurement of ascitic fluid viscosity correlates significantly with SAAG values. In view of its simplicity, low cost, small sample volume requirement and allowance for measurement in previously frozen samples, measurement of ascites viscosity could be useful for the accurate and rapid classification of ascites.
Ascites; Serum-ascites albumin gradient; Viscosity
Eosinophilic peritonitis is defined as when there are more than 100 eosinophils present per milliliter of peritoneal effluent, of which eosinophils constitute more than 10% of its total WBC count. Most cases occur within the first 4 weeks of peritoneal catheter insertion and they usually have a benign and self-limited course. We report a patient of eosinophilic peritonitis that was successfully resolved without special treatment.
An 84-year-old man with end stage renal disease secondary to diabetic nephropathy was admitted for dyspnea and poor oral intake. Allergic history was negative. and physical examination was unremarkable. Complete blood count showed a hemoglobin level of 11.1 g/dL, WBC count was 24,500/mm3 (neutrophil, 93%; lymphocyte, 5%; monocyte, 2%), platelet count was 216,000/mm3, serum BUN was 143 mg/dL, Cr was 5.7 mg/dL and albumin was 3.5 g/dL. Creatinine clearance was 5.4 mL/min. Three weeks after peritoneal catheter insertion, he was started on peritoneal dialysis with a 6-hour exchange of 2L 1.5% peritoneal dialysate. After nine days, he developed turbid peritoneal effluents with fever (38.4°C), abdominal pain and tenderness. Dialysate WBC count was 180/mm3 (neutrophil, 20%; lymphocyte, 4%; eosinophil, 76% [eosinophil count: 136/mm3]). Cultures of peritoneal fluid showed no growth of aerobic or anaerobic bacteria, or of fungus. Continuous ambulatory peritoneal dialysis (CAPD) was commenced, and he was started on intraperitoneal ceftazidime (1.0 g/day) and cefazolin (1.0 g/day). After two weeksr, the dialysate had cleared up and clinical symptoms were improved. Dialysate WBC count decreased to 8/mm3 and eosinophils were not detected in peritoneal fluid. There was no recurrence of eosinophilic peritonitis on follow-up evaluation, but he died of sepsis and pneumonia fifteen weeks after admission.
Eosinophilic Peritonitis; Peritoneal Dialysis; Continuous Ambulatory; Kidney Failure; Chronic
Cells with "hand mirror" morphology have not, to the best of our knowledge, been described in a primary effusion sample. This paper describes a case of T-cell lymphoma with eosinophilia in a patient with suspected peritoneal carcinomatosis. Rarely, a T-cell lymphoproliferative process may mimic primary peritoneal carcinomatosis, clinically suggested by a presentation in CT imaging of omental caking with bilateral massive loculated effusions in a patient without lymphadenopathy or splenomegaly.
A 60 year old caucasian male presented with vague abdominal discomfort and increasing abdominal girth. Computed tomography showed a two centimeter thick omental cake and a small loculated effusion. The clinical presentation and imaging findings were most consistent with peritoneal carcinomatosis. Cytologic evaluation of the effusion was undertaken for diagnostic study.
Rapid intraprocedural interpretation of the effusion sample showed a monomorphic population of cells with "hand-mirror" cell morphology exhibiting cytoplasmic extensions (uropodia) with 3–5 course dark cytoplasmic granules and a rim of vacuolated cytoplasm capping the opposing "mirror head" side. These cells were seen within a background of mature eosinophils. Flow cytometric evaluation of the ascites fluid demonstrated an atypical T-cell population with the following immunophenotype: CD2-, CD3+, CD4-, CD5-, CD7-, CD8+, CD56+. T-cell receptor (TCR) gene rearrangement was positive for clonal TCR-gamma gene rearrangement, supporting the diagnosis of a T-lymphoprolifereative disorder.
A T-cell lymphoproliferative process may present with "hand mirror" morphology in an effusion sample. These cells may show polar cytoplasmic vacuolization and 3–5 course granules within the "handle" of these unique cells. Cytoplasm shows peripheral constriction around the nucleus.
A major puzzle in biology is how mammalian sperm maintain the correct swimming direction during various phases of the sexual reproduction process. Whilst chemotaxis may dominate near the ovum, it is unclear which cues guide spermatozoa on their long journey towards the egg. Hypothesized mechanisms range from peristaltic pumping to temperature sensing and response to fluid flow variations (rheotaxis), but little is known quantitatively about them. We report the first quantitative study of mammalian sperm rheotaxis, using microfluidic devices to investigate systematically swimming of human and bull sperm over a range of physiologically relevant shear rates and viscosities. Our measurements show that the interplay of fluid shear, steric surface-interactions, and chirality of the flagellar beat leads to stable upstream spiralling motion of sperm cells, thus providing a generic and robust rectification mechanism to support mammalian fertilisation. A minimal mathematical model is presented that accounts quantitatively for the experimental observations.
A sperm cell must complete a long and taxing journey to stand a chance of fertilising an egg cell. This quest covers a distance that is thousands of times longer than the length of a sperm cell. It also passes through the diverse environments of the cervix, the uterus and, finally, the oviduct, where there might be an egg to fertilise. How the sperm cells manage to stay on course over this distance is a mystery, although it has been suggested that many different factors, including chemical signals and fluid flow, are involved.
The fluids that the sperm cells travel through are not static. Evidence suggests that contractions of the cervix and uterus help to pump sperm cells along the first part of their journey. However, mucus flows out of the oviduct in the opposite direction to way the sperm cells need to go.
Sperm cells mostly move along the walls of the cervix, uterus, and oviduct. This means that sperm cells must contend with two properties of the fluids they travel through—the viscosity (or ‘thickness’) of the fluid, and the fact that different parts of the fluid will flow at different speeds, depending on how close it is to the wall (‘shear flow’).
Kantsler et al. have now used a technique called microfluidics—which involves forcing tiny amounts of liquid to flow through very narrow channels—to study how the movement of human and bull sperm cells along a surface is affected by the viscosity and flow rate of the fluid they are swimming through. The sperm cells were found to swim upstream, moving along the walls of the channels in a spiral movement. This is likely to help the sperm cells to find the egg, because spiralling around the oviduct will increase the chances of meeting the egg.
Kantsler et al. also built a mathematical model that describes how the sperm cells move. Although further work is needed to better understand the role played by chemical signals, understanding how fluid flow and viscosity influence sperm cells could lead to more effective artificial insemination techniques.
sperm; rheotaxis; fertilization; human; other
•Emergency presentation of a GIST is not uncommon and one of its manifestations is acute abdome.•The cases described in the literature are the tip of the iceberg and spontaneous rupture or perforation of GISTs are a far more frequent first presentation of this rare tumour.•The jejunum was the more common location of perforation compared to the ileum.•Emergency surgery is mandatory and should achieve radical resection.
A few cases of acute abdomen caused by perforation of small-intestinal gastrointestinal stromal tumours (GISTs) have been reported in the literature.
Presentation of case
Together with a review of the published cases, here we report a case of an elderly patient with peritonitis due to spontaneous perforation of a GIST of the jejunum. An 82-year-old man was admitted to the emergency unit of our hospital with fever and severe abdominal pain. An abdominal enhanced computed tomography scan detected a 6 cm solid mass in the left upper quadrant adherent to a jejunal loop and surrounded by free fluid and free air. Due to the radiological features of the mass, the diagnosis of a perforation of a GIST arising from the jejunum wall was suspected. The patient underwent emergency laparotomy. Intraoperative findings confirmed diffuse peritonitis secondary to jejunal tumour perforation. A segmental resection of the jejunum containing the mass was performed followed by a mechanical end-to-side anastomosis. The histopathologic examination of the mass confirmed the diagnosis of a perforated GIST of the small intestine (high-risk category). The post-operative course was uneventful and the patient was treated with adjuvant imatinib therapy.
Twenty-one other cases of spontaneous perforation of small intestine GISTs are reported in the literature and are summarized in the present review.
The described case is the tip of the iceberg and spontaneous rupture or perforation of GISTs are a far more frequent first presentation of this rare tumour.
GIST(s), Gastrointestinal stromal tumours; GI, Gastrointestinal; CT, Computed tomography; H&E, Hematoxylin and Eosin; Gastrointestinal stromal tumours; Small intestine; Peritonitis
Spontaneous bacterial peritonitis (SBP) is a rare affection in the pediatric population. It usually occurs when concurrent conditions are present, such as nephrotic syndrome, peritoneal dialysis or liver disease. We report a case of spontaneous bacterial peritonitis due to Kocuria marina in a 2-year-old child with no underlying risk factor. This is both the first description of an infection caused by this rare pathogen in a child and the first reported case of primary peritonitis caused by K. marina in a patient with no predisposing condition.
A 2 year-old boy presented to the Pediatric Emergency Department with clinical signs of peritonitis. Laparoscopic surgical exploration confirmed purulent, generalized peritonitis without perforation. Culture of the peritoneal fluid revealed the presence of Kocuria marina, a Gram-positive coccoid environmental bacteria. After peritoneal lavage and appropriate antibiotic treatment, the patient improved and was discharged without sequel.
The present report illustrates the first clinical presentation of Kocuria marina SBP in a child with no underlying risk factor. Although never previously described in healthy patients, this pathogen may therefore be considered as a possible cause of SBP in a child. This unusual finding extends the spectrum of infectious diseases caused by Kocuria marina beyond the scope of the previously described susceptible population.
Spontaneous bacterial peritonitis; Primary peritonitis; Pediatrics; Kocuria; Kocuria marina
Spontaneous bacterial peritonitis (SBP) as a monomicrobial infection of ascites fluid is one of the most important causes of morbidity and mortality in cirrhotic patients. This study was aimed to determine the diagnostic accuracy of ascites fluid color in detection of SBP in cirrhotic cases referred to the emergency department.
Cirrhotic patients referred to the ED for the paracentesis of ascites fluid were enrolled. For all studied patients, the results of laboratory analysis and gross appearance of ascites fluid registered and reviewed by two emergency medicine specialists. The sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ration of the ascites fluid gross appearance in detection of SBP were measured with 95% confidence interval.
The present project was performed in 80 cirrhotic patients with ascites (52.5 female). The mean of the subjects’ age was 56.25±12.21 years (35-81). Laboratory findings revealed SBP in 23 (29%) cases. Fifty nine (73%) cases had transparent ascites fluid appearance of whom 17 (29%) ones suffered from SBP. From 21 (26%) cases with opaque ascites appearance, 15 (71%) had SBP. The sensitivity and specificity of the ascites fluid appearance in detection of SBP were 46.88% (Cl: 30.87-63.55) and 87.50% (95% Cl: 75.3-94.14), respectively.
It seems that the gross appearance of ascites fluid had poor diagnostic accuracy in detection of SBP and considering its low sensitivity, it could not be used as a good screening tool for this propose.
Peritonitis; ascites; diagnostic tests; routine; mass screening
Peritoneal tuberculosis is an important problem in regions of the world where tuberculosis is still prevalent (Chest 1991; 99:1134). Atypical presentations such as portal vein thrombosis can delay diagnosis or result in misdiagnosis (Gut 1990; 31:1130, Acta ClinBelg 2012; 67(2):137–9, J Cytol Histol 2014; 5:278, Digestive Diseases and Sciences 1991; 36(1):112–115). A high index of suspicion is required for the diagnosis of peritoneal tuberculosis, as the analysis of peritoneal fluid for tuberculous bacillus is often ineffective, and may increase mortality due to delayed diagnosis. (Clin Effect Dis 2002;35: 409-13) In light of new evidence, peritoneal biopsy through laparoscopy or laparotomy has emerged as the gold standard for diagnosis (Clin Effect Dis 2002; 35: 409-13).
We report a case of a 35 year old Sri Lankan female employed in a Middle - Eastern country who presented with progressive abdominal distention and constitutional symptoms for four months duration. She had been investigated abroad and diagnosed with ascites with chronic portal vein thrombosis following which warfarin therapy had been commenced suspecting an underlying thrombophilia. Despite treatment her symptoms had worsened. Therefore she had decided to return to Sri Lanka for further evaluation. After ruling out inherited thrombophilic states and the antiphospholipid syndrome, further investigations revealed a transudative ascites and high inflammatory markers. The tuberculosis work up on peritoneal fluid was negative. Therefore, we proceeded with laparoscopy which showed multiple nodular deposits on abdominal wall, bowel and omentum and peritoneal biopsy revealed granulomatous inflammation with caseous type necrosis compatible with mycobacterium tuberculosis infection. This was confirmed by tuberculosis genome identification on the biopsy sample confirming a diagnosis of peritoneal tuberculosis with secondary portal vein thrombosis and cavernous formation due to local inflammation. The patient was started on anti-tuberculosis treatment and warfarin was discontinued, following which she made a remarkable recovery.
Peritoneal tuberculosis can present with unusual manifestations such as portal vein thrombosis and transudative ascites causing a diagnostic dilemma. Ascitic fluid analysis is generally not diagnostic. Under such circumstances peritoneal biopsy should be performed as it has a good diagnostic yield and accuracy.
Peritoneal tuberculosis; Portal vein thrombosis; Transudative ascites
An 85-year-old woman was admitted to our hospital for steroid therapy for relapsing nephrotic syndrome. During hospitalization, she complained of sudden epigastric pain at night. Although there were signs of peritoneal irritation, CT showed a large amount of ascitic fluid, but no free intraperitoneal gas. Gram staining of ascitic fluid obtained by abdominal paracentesis showed Gram-negative rods, which raised a strong suspicion of gastrointestinal perforation and peritonitis. Therefore, emergency surgery was performed. Exploration of the colon showed multiple sigmoid diverticula, one of which was perforated. The patient underwent an emergency Hartmann's procedure. Imaging studies failed to reveal any evidence of gastrointestinal perforation, presenting a diagnostic challenge. However, a physician performed rapid Gram staining of ascitic fluid at night when laboratory technicians were absent, had a strong suspicion of gastrointestinal perforation, and performed emergency surgery. Gram staining is superior in rapidity, and ascitic fluid Gram staining can aid in diagnosis, suggesting that it should be actively performed. We report this case, with a review of the literature on the significance of rapid diagnosis by Gram staining.
AIM: To evaluate effective alternative antibiotics in treatment of cefotaxime-resistant spontaneous bacterial peritonitis.
METHODS: One hundred cirrhotic patients with spontaneous bacterial peritonitis [ascitic fluid polymorphonuclear cell count (PMNLs) ≥ 250 cells/mm3 at admission] were empirically treated with cefotaxime sodium 2 g/12 h and volume expansion by intravenous human albumin. All patients were subjected to history taking, complete examination, laboratory tests (including a complete blood cell count, prothrombin time, biochemical tests of liver and kidney function, and fresh urine sediment), chest X-ray, a diagnostic abdominal paracentesis, and the sample subjected to total and differential cell count, chemical examination, aerobic and anaerobic cultures. Patients were divided after 2 d by a second ascitic PMNL count into group I; patients sensitive to cefotaxime (n = 81), group II (n = 19); cases resistant to cefotaxime (less than 25% decrease in ascitic PMNL count). Patients of group II were randomly assigned into meropenem (n = 11) or levofloxacin (n = 8) subgroups. All patients performed an end of treatment ascitic PMNL count. Patients were considered improved when: PMNLs decreased to < 250 cells/mm3, no growth in previously positive culture cases, and improved clinical manifestations with at least 5 d of antibiotic therapy.
RESULTS: Age, sex, and Child classes showed no significant difference between group I and group II. Fever and abdominal pain were the most frequent manifestations and were reported in 82.7% and 80.2% of patients in group I and in 94.7% and 84.2% of patients in group II, respectively. Patients in group II had a more severe ascitic inflammatory response than group I and this was demonstrated by more ascitic lactate dehydrogenase (LDH) [median: 540 IU/L (range: 150-1200 IU/L) vs median: 240 IU/L (range: 180-500 IU/L), P = 0.000] and PMNL [median: 15 000 cell/mm3 (range: 957-23 822 cell/mm3) vs 3400 cell/mm3 (range: 695-26 400 cell/mm3), P = 0.000] counts. Ascitic fluid culture was positive in 32% of cases. Cefotaxime failed in 19% of patients; of these patients, 11 (100%) responded to meropenem and 6 (75%) responded to levofloxacin. Two patients with failed levofloxacin therapy were treated according to the in vitro culture and sensitivity (one case was treated with vancomycin and one case was treated with ampicillin/sulbactam). In group II the meropenem subgroup had higher LDH (range: 108-860 IU/L vs 120-491 IU/L, P = 0.042) and PMNL counts (range: 957-23 822 cell/mm3
vs 957-15 222 cell/mm3, P = 0.000) at initiation of the alternative antibiotic therapy; there was no significant difference in the studied parameters between patients responsive to meropenem and patients responsive to levofloxacin at the end of therapy (mean ± SD: 316.01 ± 104.03 PMNLs/mm3
vs 265.63 ± 69.61 PMNLs/mm3, P = 0.307). The isolated organisms found in group II were; enterococci, acinetobacter, expanded-spectrum β-lactamase producing Escherichia coli, β-lactamase producing Enterobacter and Staphylococcus aureus.
CONCLUSION: Empirical treatment with cefotaxime is effective in 81% of cases; meropenem is effective in cefotaxime-resistant cases.
Spontaneous bacterial peritonitis; Cefotaxime; Ascitic polymorphonuclear count; Cirrhosis; Meropenem; Levofloxacin
Eosinophilic peritonitis is a well-described complication of peritoneal dialysis and is often associated with either a reaction to the dialysis system constituent (tubing, sterilant or solution) or an underlying bacterial or fungal reaction. We report a case of eosinophilic peritonitis, which is treated by oral prednisone acetate therapy. A 43-year-old female patient developed end-stage renal disease and underwent continuous ambulatory peritoneal dialysis for 2.5 years. The patient received 2,000 ml of 1.5% dialysis solution (PD2) with three exchanges daily and 2,000 ml of 2.5% PDF overnight (PD2). She went to the consultation because of a constant turbid peritoneal dialysis effluent for 3 months without abdominal pain. Repeated peritoneal effluent samples showed an elevated white blood cell count of 500 cells/mm3, with 87% eosinophils. The peripheral blood test revealed a white blood cell count of 3.8 × 109/l, with 32.2% eosinophils. Etiology like bacterial and fungal infection was excluded by peritoneal fluid culture. Turbidness persisted in spite of diagnostic antibiotic treatment. Given the fact that we found a significant elevation of eosinophils in the peripheral blood and an absolute increase in the eosinophil count of >30/mm3 in dialysis fluid (up to 400/mm3 in our patient), obvious dialysate effluent turbidness, negative results of repeated peritoneal fluid cultures, inefficacy of antibiotic therapy, and negativity of serum tumor and immunological markers, we drew the conclusion that the patient had idiopathic eosinophilic peritonitis. Oral corticosteroid was administered at once (20 mg prednisone acetate daily), which was gradually weaned off and stopped over an 8-week period. Afterwards, the dialysis effluent became clear, and the cytological analysis showed that the white blood cell count decreased to 1 × 106/l, with no eosinophils. This case reminds us that the diagnosis of eosinophilic peritonitis should be considered when repeated cultures are always negative and the turbidness of peritoneal dialysis effluent persists in spite of an antibiotic therapy.
Idiopathic eosinophilic peritonitis; Continuous ambulatory peritoneal dialysis; Turbidness; Corticosteroid therapy
Malignant peritoneal mesothelioma is a well-described entity in many reports in the literature in which it has been associated with asbestosis. However, there is no information describing the gross appearance and cardinal features seen during laparotomy, hence it is easy for the unwary surgeon to miss the diagnosis of this rare condition.
A 49-year-old man of African descent presented to our hospital with a three-month history of weight loss, anorexia, abdominal distension, and general signs of cachexia and ascites on second presentation. At first presentation one year prior to this, he had undergone a laparotomy at our institution by a different team for intestinal obstruction secondary to adhesions with no biopsy taken. The patient's condition subsequently progressively deteriorated, and investigations including upper and lower gastrointestinal endoscopies and computed tomography of the abdomen were inconclusive, except for some free fluid in the peritoneal cavity and diffuse, mild thickening of the gut wall and mesentery. A second-look exploratory laparotomy revealed widespread nodular thickening of the visceral peritoneum with a striking, uniformly diffuse, erythematous, and velvety appearance. The peritoneal biopsy histology showed that the patient had malignant peritoneal mesothelioma. His condition deteriorated rapidly, and he died eight weeks after surgery.
Our report aims to increase the diagnosing clinician's awareness of the cardinal features of malignant peritoneal mesothelioma and thus reduce diagnostic errors and delays in treatment.
peritoneal mesothelioma; clinical appearance
Urachal diseases are rare and may develop from a congenital anomaly in which a persistent or partial reopening of the fetal communication between the bladder and the umbilicus persists. The most frequently reported urachal anomalies in adults are infected urachal cyst and urachal carcinoma. The diagnosis of this entity is not always easy because of the rarity of these diseases and the atypical symptoms at presentation. Imaging techniques, such as ultrasonography and computed tomography have a significant role in recognizing the presence of urachus-derived lesions.
Case presentation 1: A 25-year-old Arab-Berber man presented with a 10-day history of progressive lower abdominal pain accompanied by fever, vomiting, and low urinary tract symptoms to our emergency department. Laboratory data revealed leucocytosis. The diagnosis of an acute peritonitis was made initially. Abdominal ultrasonography revealed a hypoechoic tract from the umbilicus to the abdominal wall, and the diagnosis was rectified (infected urachal remnants). The patient was initially treated with intravenous antibiotics in combination with a percutaneous drainage. Afterwards an extraperitoneal excision of the urachal remnant including a cuff of bladder was performed. The histological analysis did not reveal a tumor of the urachal remnant. Follow-up examinations a few months later showed no abnormality.
Case presentation 2: A 35-year-old Arab-Berber man, without prior medical history with one week of abdominal pain, nausea and vomiting, associated with fever but without lower urinary tract symptoms visited our emergency department. Laboratory data revealed leucocytosis. Abdominal ultrasonography was not conclusive. Computed tomography of the abdomen was the key to the investigation and the diagnosis of an abscess of urachal remnants was made. The patient underwent the same choice of medical-surgical treatment as previously described for case one, with a good follow-up result.
Case presentation 3: A 22-year-old Arab-Berber man, with no relevant past medical history, presented to our emergency department because of suspected acute surgical abdomen. Physical examination revealed umbilical discharge with erythema and a tender umbilical mass. Abdominal ultrasonography and computed tomography scan confirmed the diagnosis of infected urachal sinus. Initial management was intravenous antibiotics associated with a percutaneous drainage with a good post-operative result, but a few days later, he was readmitted with the same complaint and the decision was made for surgical treatment consisting of excision of the infected urachal sinus. The clinical course was uneventful. Histological examination did not reveal any signs of malignancy.
We describe our clinical observations and an analysis of the existing literature to present the various clinical, radiological, pathological and therapeutic aspects of an abscess of urachal remnants. To the best of our knowledge, this manuscript is an original case report because this atypical presentation is rarely reported in the literature and only a few cases have been described.
Urachus; Bladder; Neoplasms; Urachal cyst; Urachal remnant; Urachal sinus; Abcess
Patient: Male, 72
Final Diagnosis: Systemic amyloidosis
Clinical Procedure: Liver biopsy
Specialty: Gastroenterology and Hepatology
Unusual clinical course
Amyloidosis is a systemic disease known to affect a vast range of organs, including the liver, heart, and kidney. When infiltrating the liver, amyloidosis typically does not present with cirrhosis. Typical presentation includes hepatomegaly with some mild laboratory abnormalities.
A 72-year-old man presented with a 2-week history of worsening abdominal, scrotal, and extremity swelling. He endorsed melanotic stools and intermittent dizziness with a 10-pound weight gain. Vitals revealed a blood pressure of 82/57 mmHg and a pulse of 83 beats/min with positive orthostatic changes. Mild bibasilar crackles were noted. His abdomen was moderately distended with a fluid wave present, but no hepatosplenomegaly was noted. He displayed anasarca with significant extremity and scrotal edema, but no jaundice, telangiectasias, or other stigmata of chronic liver disease were present. Liver function tests demonstrated a total bilirubin of 1.5 mg/dL (normal value: 0.2–1.2 mg/dL), AST 111 IU/L (normal value 5–34 IU/L), ALT 51 IU/L (normal value 5–55 IU/L), and GGT 583 U/L (12–64 U/L). Alkaline phosphatase was 645 U/L (40–150 U/L). Analysis of peritoneal fluid was consistent with portal hypertension due to liver disease. Given an atypical presentation of cirrhosis with unclear etiology, a biopsy was performed and revealed amyloid deposition.
Liver disease can be due to various etiologies, many of which can present ambiguously. Although the most typical etiologies have been well defined, we present a case of an atypical presentation of hepatic amyloidosis discovered in a patient with ascites and without typical hepatomegaly.
Amyloidosis; Ascites; Cirrhosis
Lachancea fermentati is an environmental yeast that is also used in the fermentation of alcoholic drinks. It has not previously been described as a human pathogen although the closely related yeast, Saccharomyces boulardii, can cause fungemia. Here we report a case of L. fermentati acting as a pathogen in a septic patient with cultures positive from blood, peritoneal fluid, bile, and sputum.
A 36 year-old Caucasian man was hospitalized with acute alcoholic hepatitis complicated by Escherichia coli spontaneous bacterial peritonitis. Three days after admission, he developed new fevers with sepsis requiring mechanical ventilation and vasopressor support. He was found to have a bowel perforation. Cultures from blood, peritoneal fluid, and sputum grew a difficult-to-identify yeast. Micafungin was started empirically. On hospital day 43 the yeast was identified as L. fermentati with low minimum inhibitory concentrations (by Epsilometer test) to all antifungals tested. Micafungin was changed to fluconazole to complete a 3-month course of therapy. Serial peritoneal fluid cultures remained positive for 31 days. One year after his initial hospitalization the patient had ongoing cirrhosis but had recovered from fungemia.
This case demonstrates the need for clinicians to consider host factors when interpreting culture results with normally non-pathogenic organisms. In this immunocompromised host L. fermentati caused disseminated disease. We believe his hobby of brewing alcohol led to colonization with L. fermentati, which then resulted in invasive disease when the opportunity arose.
Lachancea fermentati; Fungemia; Opportunistic pathogen
Vernix caseosa peritonitis (VCP) is a very unusual complication caused by inflammatory response to amniotic fluid spilled into the maternal peritoneal cavity. Twenty-seven cases have been reported, and all occurred after cesarean section.
We present a case of VCP following vaginal delivery; this may be the first case reported after vaginal delivery. Mrs. A, 28 years old, gravida 3, para 2, with one previous cesarean section, was admitted at 41 weeks gestation in active labor. Vacuum extraction was performed to deliver a healthy male baby, 4.410 kg, Apgar scores 7, 8. She developed fever, acute abdominal pain, and distension about 3 hours after delivery. A diagnosis of acute abdomen was made. Laparotomy was performed and it revealed neither uterine scar rupture nor other surgical emergencies, but 500 mL of turbid fluid and some cheesy material on the serosal surface of all viscera. Biopsies were taken. She had a course of antibiotics and her recovery was complete. Histology of the peritoneal fluid and tissue biopsy resulted in a diagnosis of VCP.
Clinical diagnosis of peritonitis due to vernix caseosa should be considered in patients presenting postpartum with an acute abdomen after vaginal delivery.
vernix caseosa peritonitis; vaginal delivery; laparotomy
Peritoneal dialysis-related peritonitis remains a major complication of peritoneal dialysis in patients with end-stage renal disease. Chryseobacterium indologenes is a rare organism that has been reported to cause infections mostly in hospitalised patients with severe underlying diseases. We report the first case of C indologenes peritonitis in a patient on peritoneal dialysis outside of Asia. Our patient with end-stage renal disease on peritoneal dialysis grew C indologenes from peritoneal fluid when he presented with abdominal pain and cloudy effluent. The patient responded well to intraperitoneal antibiotic therapy. Tenckhoff catheter did not require removal. This case demonstrates the importance of considering rare causes of peritonitis, such as C indologenes, in patients on peritoneal dialysis. Given the resistance of such organisms to commonly used broad-spectrum antibiotics, antimicrobial susceptibility testing must be assessed as early as possible to assure appropriate antibiotic coverage to avoid untreated peritonitis leading to peritoneal dialysis failure.
Endemic to the southwestern parts of the United States, coccidioidomycosis, also known as “Valley Fever,” is a common fungal infection that primarily affects the lungs in both acute and chronic forms. Disseminated coccidioidomycosis is the most severe but very uncommon and usually occurs in immunocompromised individuals. It can affect the central nervous system, bones, joints, skin, and, very rarely, the abdomen. This is the first case report of a patient with coccidioidal dissemination to the peritoneum presenting as eosinophilic ascites (EA). A 27-year-old male presented with acute abdominal pain and distention from ascites. He had eosinophilia of 11.1% with negative testing for stool studies, HIV, and tuberculosis infection. Ascitic fluid exam was remarkable for low serum-ascites albumin gradient (SAAG), PMN count >250/mm3, and eosinophils of 62%. Abdominal imaging showed thickened small bowel and endoscopic testing negative for gastric and small bowel biopsies. He was treated empirically for spontaneous bacterial peritonitis, but no definitive diagnosis could be made until coccidioidal serology returned positive. We noted complete resolution of symptoms with oral fluconazole during outpatient follow-up. Disseminated coccidioidomycosis can present in an atypical fashion and may manifest as peritonitis with low SAAG EA. The finding of EA in an endemic area should raise the suspicion of coccidioidal dissemination.
The inevitable post-inflammatory fibrosis and adhesion often compromises future treatment in peritoneal dialysis patients. Here, we describe a patient who experienced an unusual form of peritoneal adhesion that made her give up peritoneal dialysis. However, its unique pattern also saved her from infection caused by bowel perforation.
The female patient discontinued peritoneal dialysis due to gradual dialysis inadequacy. Two months after shifting to hemodialysis with generally improved sense of well-being and no sign of abdominal illness, she was admitted to remove the Tenckhoff catheter. The procedure was smooth, but fever and abdominal pain not at the site of operation developed the next day. Abdominal ultrasound showed the presence of ascites and aspiration revealed slimy, green-yellowish pus that gave a negative result on bacterial culture. Abdominal computed tomography (CT) with oral contrast medium was performed, but failed to demonstrate the suspected bowel perforation. The examination, however, did show accumulation of pus inside the abdomen but outside the peritoneal cavity. We drained the pus with two 14-F Pig-tail catheters and the total amount of drainage approached 4000 ml. The second CT was performed with double dose of the contrast medium and found a leak of the contrast from the jejunum. She then received laparotomy and had the perforation site closed.
In summary, this uremic patient suffered from pus accumulation inside her abdomen without obvious systemic toxic effect. The bowel perforation and pus formation might be caused by repeated peritonitis, but the peritoneal adhesion itself might also isolate her peritoneal cavity from the anticipated toxic injuries of bowel perforation.
Peritoneal dialysis; Peritonitis; Ultrafiltration failure; Peritoneal adhesion; Encapsulating peritoneal sclerosis