See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/49673951 An Unusual Presentation of Vaginal Leakage in a Peritoneal Dialysis Patient Article in Peritoneal Dialysis International · November 2010 DOI: 10.3747/pdi.2009.00229 · Source: PubMed CITATIONS READS 5 164 5 authors , including: Mustafa Altay Selman Unverdi Sa ğ l ı k Bilimleri Üniversitesi Sanko University 135 PUBLICATIONS 566 CITATIONS 53 PUBLICATIONS 371 CITATIONS SEE PROFILE SEE PROFILE Ilhan Kurultak Trakya University 47 PUBLICATIONS 90 CITATIONS SEE PROFILE Some of the authors of this publication are also working on these related projects: Can Neutrophil/Lymphocyte Ratio Be Used as an Indicator of Inflammation in Patients with Hyperthyroidism? View project Rhabdomyolysis during tuberculosisi therapy View project All content following this page was uploaded by Ilhan Kurultak on 24 November 2015. The user has requested enhancement of the downloaded file.
PDI NOVEMBER 2010 – VOL. 30, NO. 6 CORRESPONDENCE A 39-year-old woman with IgA nephropathy was com- DISCLOSURES menced on nocturnal intermittent PD in 2007 after a failed renal transplant and recurrent vascular access The authors do not have any conflicts of interest to problems. To improve dialysis adequacy, daytime ex- declare. changes were needed 1 year later following an episode of uremic pericarditis. The patient presented in 2010 K.M. Chow* with her first episode of peritonitis. Analysis of the peri- W.F. Pang toneal effluent demonstrated a white cell count of C.C. Szeto 730/mm 3 , with 59% neutrophils. The patient was treated P.K.T. Li initially with intraperitoneal cefazolin and ceftazidime. Gram stain revealed the presence of gram-negative ba- Division of Nephrology cilli: cefazolin was discontinued. Resolution of perito- Department of Medicine and Therapeutics neal fluid cloudiness was noted within 3 days of Prince of Wales Hospital initiation of antibiotics but the identity of the gram- Chinese University of Hong Kong negative organism remained obscure over the ensuing Hong Kong 3 weeks. The organism was subsequently identified as a Capno- *e-mail: Chow_Kai_Ming@alumni.cuhk.net Downloaded from cytophaga species. Further questioning revealed the pa- tient had two cats as household pets. There was no REFERENCES history of animal bites but the patient admitted to hav- 1. Chadha V, Warady BA. Capnocytophaga canimorsus peri- ing been regularly licked on the face by her two favorite tonitis in a pediatric peritoneal dialysis patient. Pediatr http://www.pdiconnect.com/ domestic cats. The patient was fond of kissing her cats Nephrol 1999; 13:646–8. and seldom wore a mask during the PD exchange proce- 2. Pers C, Tvedegaard E, Christensen JJ, Bangsborg J. Capno- dure. She also reported fair adherence to proper hand cytophaga cynodegmi peritonitis in a peritoneal dialysis washing after contact with her cats. The cats were al- patient. J Clin Microbiol 2007; 45:3844–6. lowed in her room except while she was performing PD 3. Esteban J, Albalate M, Caramelo C, Reyero A, Carriazo MA, exchanges. She could not exclude contamination by cat Hernandez J, et al . Peritonitis involving a Capnocytophaga fur and dander because she switched on an electric fan sp. in a patient undergoing continuous ambulatory peri- heater at the time of the exchange procedure on the by guest on January 4, 2012 toneal dialysis. J Clin Microbiol 1995; 33:2471–2. evening prior to developing peritonitis. In light of 4. Mat O, Moenens F, Beauwens R, Rossi C, Muniz-Martinez the patient’s lifestyle, her exposure to cats is considered MC, Mestrez F, et al . Indolent Pasteurella multocida peri- the primary source of her Capnocytophaga infection. tonitis in a CCPD patient. 25 years of “cat-bite peritoni- tis”: a review. Perit Dial Int 2005; 25:88–90. The prolonged period required to identifying Capno- doi:10.3747/pdi.2010.00070 cytophaga species is related to the slow growth of these thin gram-negative rods that are facultative anaerobes. The name of the organism derives from its property as An Unusual Presentation of Vaginal the “eater of carbon dioxide” because Capnocytophaga Leakage in a Peritoneal species grow best in a carbon dioxide-enriched atmo- Dialysis Patient sphere. Both C. canimorsus and C. cynodegmi are part of the normal flora of dogs and cats. Peritonitis infection with Capnocytophaga species has been reported in only Editor: 3 PD patients (1–3). Of the three cases reported in the Dialysate leaks in peritoneal dialysis (PD) are clini- literature, two were highly suspicious of cat-associated cally important because they may cause fluid retention peritonitis. One patient on nocturnal automated PD re- and a consequent decrease in fluid removal and clear- ported sleeping with his domestic cat, which had punc- ance. There are few reports on the diagnosis and man- tured the PD tubing (1), whereas the other had frequent agement of vaginal leakage in PD. Recurrent and visits by the neighbor’s cat, which he occasionally refractory peritonitis may lead to the formation of sub- fed (2). compartments in the peritoneal cavity as a result of ad- In addition to the relatively well-known transmission hesions. We present here a case of a patient in whom of Pasteurella multocida from cats (4), we believe that recurrent peritonitis led to formation of a subcompart- Capnocytophaga infection should also be considered in ment in the peritoneal cavity, which was then compli- PD patients in close contact with cats. cated by intractable vaginal leakage. This single copy is for your personal, non-commercial use only. 663 For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at marketing@multi-med.com
CORRESPONDENCE NOVEMBER 2010 – VOL. 30, NO. 6 PDI A 27-year-old woman had been on continuous ambu- catheter by the fimbriae of the fallopian tube (7). In our latory PD treatment with 2 L 4 times daily for 15 months. patient, vaginal leakage may have been related to cap- Despite eight peritonitis episodes, she refused to trans- ture of the PD catheter by the fallopian tube fimbriae in fer to hemodialysis. Her PD catheter was changed twice a subcompartment of the peritoneal cavity, which had because of these recurrent peritonitis episodes. Six formed due to adhesions related to recurrent peritoni- months after her most recent catheter change, she pre- tis. Radiologic methods are important in the diagnosis sented with a 4-week history of dialysate leakage of vaginal leakage. In our case, peritoneal thickening through her vagina. Physical examination was normal, was revealed by abdominal CT. Peritoneography with as was the abdominal ultrasound. Abdominal CT showed contrast confirmed the accumulation of dialysis solution thickening of the visceral and parietal peritoneum. Con- in a subcompartment that was communicating with the trast peritoneography was conducted in order to inves- vagina. tigate the vaginal leakage (Figure 1). The dialysate did This mechanism of vaginal leakage has not previously not diffuse homogenously throughout the cavity, collect- been described. ing instead in a subcompartment and then passing out through the uterine cavity. The patient was switched to DISCLOSURES hemodialysis after removal of the PD catheter. Peritonitis may be complicated by peritoneal thick- The authors did not receive financial support. Downloaded from ening, loculated fluid collections, abscesses, and adhe- M. Ceri 1 * sions (1). Extraperitoneal dialysate leakage is a M. Altay 2 well-recognized complication of PD and is related to in- S. Unverdi 1 creased abdominal pressure (2). It usually occurs in the I. Kurultak 3 http://www.pdiconnect.com/ anterior abdominal wall or the pelvis (3) and recurs in M. Duranay 1 as many as 5% of PD patients (4). Vaginal leakage is much less common (5–7). It may be due to erosion of the cath- Department of Nephrology 1 eter through the peritoneum lining the pouch of Dou- Department of Internal Medicine 2 glas or to leakage of dialysate through the fallopian tubes (8). A related complication is capture of the PD Ankara Education and Research Hospital Department of Nephrology 3 by guest on January 4, 2012 Ankara University Faculty of Medicine Ankara, Turkey *e-mail: tscer@yahoo.com REFERENCES 1. Cakir B, Kirbas I, Cevik B, Ulu EM, Bayrak A, Coskun M. Complications of continuous ambulatory peritoneal dialy- sis: evaluation with CT. Diagn Interv Radiol 2008; 14: 212–20. 2. Bargman JM. Complications of peritoneal dialysis related to increased intraabdominal pressure. Kidney Int 1993; 40:75–80. 3. Leblanc M, Ouimet D, Pichette V. Dialysate leaks in peri- toneal dialysis. Semin Dial 2001; 14:50–4. 4. Tzamaloukas AH, Gibel LJ, Eisenberg B, Goldman RS, Kanig SP, Zager PG, et al . Early and late peritoneal dialysate leaks in patients on CAPD. Adv Perit Dial 1990; 6:64–71. 5. Coward RA, Gokal R, Wise M, Mallick NP, Warrell D. Perito- nitis associated with vaginal leakage of dialysis fluid in continuous ambulatory peritoneal dialysis. Br Med J 1982; Figure 1 — Peritoneography demonstrates leakage through 284:1529. fallopian tubes (a) and the contrast agent shows accumula- 6. Whiting MA, Smith NI, Agar JW. Vaginal peritoneal dialy- tion of the dialysis solution in a subcompartment (b); Tenck- hoff catheter (c). sate leakage per fallopian tubes. Perit Dial Int 1995; 15:85. This single copy is for your personal, non-commercial use only. 664 For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at marketing@multi-med.com
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