Intraperitoneal hydrocortisone in eosinophilic peritonitis associated with continuous ambulatory peritoneal dialysis

Eosinophilic peritonitis in children undergoing maintenance peritoneal dialysis: A case report and literature review

Eosinophilic peritonitis (EP) constitutes a significant number of culture-negative peritonitis cases that can affect 16-60% of the patients who are treated with maintenance peritoneal dialysis (PD). Although it is mainly considered to be the hypersensitivity response of the peritoneum to foreign substances, it can also develop following culture-positive peritonitis attacks. Besides the presence of more than 100 white blood cells (WBC)/ml, the diagnosis is made with the high number of eosinophils in the dialysate fluid (>10%), usually accompanied by peripheral eosinophilia. In this study, a 12-year-old male patient, who was diagnosed as EP as early as in the first week of PD catheter placement and treated with systemic antihistamines was reported. Additionally, clinical aspects and treatment modalities of EP are presented with a detailed literature review. Although EP is usually a self-limiting clinical manifestation with a benign outcome, it can be overlooked due to the lack of a routine reporting of the count and percentage of peritoneal eosinophils in most centers. For this reason, a detailed examination in culture-negative peritonitis cases for EP in order to avoid unnecessary antibiotic use for these patients should be the strategy.

Factors Predisposing and Contributing to Peritonitis during Chronic Peritoneal Dialysis in Children: A Ten-Year Experience

Factors contributing and predisposing to peritonitis were studied retrospectively in 83 children treated with continuous ambulatory (CAPD) or continuous cycling peritoneal dialysis (CCPD) from 1978 to 1988. Recurrent peritonitis was the most frequent complication and the major reason for peritoneal dialysis failure. Fifty patients had 171 episodes of peritonitis during the ten years and 33 remained peritonitis -free. The duration of dialysis was significantly shorter in the peritonitis-free group. The incidence of peritonitis was lower with CCPD than with CAPD. Leucopenia was not a predisposing factor nor was blood leucocytosis helpful in diagnosing peritonitis. Serum IgG was low in 33% of patients with episodes of peritonitis, but there was no correlation or predictive value in this finding. The C3 component of complement was relatively lower than the C4 but both components were usually in the normal range. Serum albumin was low in all patients, but lower in those with peritonitis episodes. Age, sex, primary disease, diapers, pyelostomies, dialysis training, and living conditions were not significantly associated risk factors. Sterile dressings gave no benefit over the shower technique. Patient noncompliance, upper respiratory tract infection, skin infections, and dental treatment were potential risk factors. However, peritonitis seemed to be distributed randomly among the patients.

Serositis: Comparative Analysis of Histological Findings and Pathogenetic Mechanisms in Nonbacterial Serosal Inflammation

Peritonitis is the established term for infective inflammation of the peritoneum, while serositis generally refers to nonorganismal inflammation in any serous cavity, including the peritoneum. In continuous ambulatory peritoneal dialysis (CAPD) literature, however, culture-negative peritoneal inflammation is referred to as “sterile” or “chemical” peritonitis. These terms not only imply unwarranted etiologic assumptions, but may also deflect attention from the existence of medical conditions to which the peritoneum is subject. This is evident in CAPD literature where there is little recognition that the peritoneum, as a member of the serosa and a secretor of lamellar bodies, is prey to a wide range of disorders. Thus before, during, and after CAPD, the membrane is liable to fall victim to disease states unconnected with the process of dialysis. Significant peritoneal pathology occurs as part of a pan-serositis, which may be metabolic (uremia, cholesterolosis), autoimmune (systemic lupus erythematosus, rheumatoid disease, acute rheumatism, endocrinopathies), genetic (recurrent hereditary polyserositis), allergic (eosinophilic serositis), and granulomatous in nature. This paper presents a comparative analysis of histopathological presentation and pathogenetic mechanisms involved in all forms of peritoneal serositis. It incorporates recent advances in molecular biology of the membrane into a holistic reappraisal of peritoneal pathology, revealing hitherto unrecognized homologies in peritoneal reaction to diverse disorders.

Eosinophilia and Kidney Disease: More than Just an Incidental Finding?

Peripheral blood eosinophilia (PBE), defined as 500 eosinophils or above per microliter (µL) blood, is a condition that is not uncommon but often neglected in the management of patients with chronic kidney disease (CKD), acute kidney injury (AKI), or patients on renal replacement therapy (RRT). The nature of PBE in the context of kidney diseases is predominantly secondary or reactive and has to be distinguished from primary eosinophilic disorders. Nonetheless, the finding of persistent PBE can be a useful clue for the differential diagnosis of underdiagnosed entities and overlapping syndromes, such as eosinophilic granulomatosis with polyangiitis (EGPA), IgG4-related disease (IgG4-RD), acute interstitial nephritis (AIN), or the hypereosinophilic syndrome (HES). For patients on RRT, PBE may be an indicator for bio-incompatibility of the dialysis material, acute allograft rejection, or Strongyloides hyperinfection. In a subset of patients with EGPA, eosinophils might even be the driving force in disease pathogenesis. This improved understanding is already being used to facilitate novel therapeutic options. Mepolizumab has been licensed for the management of EGPA and is applied with the aim to abrogate the underlying immunologic process by blocking interleukin-5. The current article provides an overview of different renal pathologies that are associated with PBE. Further scientific effort is required to understand the exact role and function of eosinophils in these disorders which may pave the way to improved interdisciplinary management of such patients.

Montelukast: a novel therapeutic option in eosinophilic peritonitis

BACKGROUND

Eosinophilic peritonitis is a recognised complication of peritoneal dialysis and has an incompletely understood pathophysiology. Current treatment options, including change of dialysate, change of peritoneal dialysis modality, steroids or antihistamines, are supported only by case reports with a lack of controlled trials or evidence-based guidelines. Leukotrienes are proinflammatory arachidonic acid metabolites produced by leucocytes and are involved in eosinophil chemotaxis. Montelukast is an orally administered leukotriene receptor antagonist commonly used in managing childhood atopic illnesses and theoretically safe for use in patients with renal failure.

CASE DIAGNOSIS AND TREATMENT

We describe the first reported case of recurrent, symptomatic, eosinophilic peritonitis in a 15-year-old girl successfully treated with leukotriene receptor antagonist montelukast after changes in dialysate and treatment with antihistamines failed to adequately control eosinophilic peritoneal infiltrates or symptoms.

CONCLUSIONS

Current scientific understanding of leukotrienes and eosinophil migration suggest that montelukast may be a well-tolerated, safe and efficacious treatment for eosinophilic peritonitis complicating peritoneal dialysis. Further cases and comparative studies are required to develop an evidence base for treatment of this condition.

Eosinophilic peritonitis in children on chronic peritoneal dialysis

Eosinophilic peritonitis is a response of the peritoneum to foreign substances. It presents as cloudy dialysate and may be missed because not all laboratories report the eosinophil count, giving only the total number of polymorphonuclear cells. Over a 2-year period, eight children developed 13 episodes of eosinophilic peritonitis. Three episodes were asymptomatic other than cloudy fluid, five followed surgery and two were associated with gastroenteritis. Despite recurrent episodes, there were no adverse outcomes, although a raised peritoneal eosinophil count persisted in most cases. Eosinophilic peritonitis is under-diagnosed and may lead to unnecessary antibiotic therapy.

Acute Peritoneal Eosinophilia in a Child With Prune-Belly Syndrome Following Peritoneal Dialysis Catheter Placement

Peritoneal eosinophilia, although uncommon, was reported after placement of catheters for peritoneal dialysis. We describe a 7-year-old African-American boy with prune-belly syndrome who developed acute onset of peritoneal eosinophilia after placement of a peritoneal dialysis catheter. Peripheral-blood eosinophilia also was noted with the peritoneal eosinophilia, but was not correlative. Intraperitoneal and systemic corticosteroid therapy led to successful resolution of peritoneal eosinophilia. Radioallergosorbent tests indicated sensitization to latex. Unrecognized latex sensitization should be considered in any child with multiple urological surgeries who develops sudden onset of peritoneal eosinophilia.

Eosinophilic peritonitis in a patient with continuous ambulatory peritoneal dialysis (CAPD)

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 degrees 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.

Resolution of eosinophilic peritonitis with ketotifen

Eosinophilic peritonitis is frequently observed in patients of all ages started on peritoneal dialysis. Peritoneal effluent may or may not become noticeably turbid, and if an aliquot for white cell count is sampled at all, eosinophils will be seen to predominate. It does not usually cause concern and settles spontaneously, many times even without the clinician noticing. Occasionally, this condition lingers on for months, and a short course of intraperitoneal hydrocortisone has been shown to be effective in clearing up the eosinophilia. We report a patient with steroid-resistant eosinophilic peritonitis and its successful resolution with ketotifen.

Peritoneal eosinophilia associated with Paecilomyces variotii infection in continuous ambulatory peritoneal dialysis

A 65-year-old woman maintained on continuous ambulatory peritoneal dialysis (CAPD) presented with a 5-month history of intermittent cloudy bags and sterile peritoneal and peripheral blood eosinophilia, which failed to clear despite conventional antibiotics. Impaired catheter inflow and delayed effluent drainage gradually occurred and intracatheter streptokinase, administered to rectify catheter dysfunction, dislodged a catheter cast composed of fungal hyphae of Paecilomyces variotii. Fungal peritonitis and Paecilomyces fungemia ensued, which were treated with amphotericin B and catheter removal. Peripheral eosinophilia rapidly resolved. Paecilomyces is a saprophytic fungus found in soil and water that is capable of infecting prosthetic devices. Eosinophils may have accumulated in this case in response to particulate fungal cell antigens being washed into the peritoneal cavity during dialysis. Chronic fungal catheter infection should be excluded in cases of late onset, persistant peritoneal eosinophilia on CAPD.

Peritoneal eosinophilia in patients on continuous ambulatory peritoneal dialysis: a prospective study

A prospective study on peritoneal eosinophilia was conducted in 23 continuous ambulatory peritoneal dialysis (CAPD) patients for a mean period of 7.9 months. Peritoneal eosinophilia as defined by peritoneal eosinophil count exceeding 100/mm3 was found in 60.8% of patients. Most developed peritoneal eosinophilia within 3 months of the initiation of dialysis, although the phenomenon could occur as early as one day or as late as 6 months after dialysis. Fifty-seven percent of those with peritoneal eosinophilia also had peripheral blood eosinophilia. Although most peritoneal eosinophilic episodes subsided in a month, in one patient the process grumbled on for 150 days. The number of peritonitis episodes was not significantly different between patients with peritoneal eosinophilia and those without. The only distinction between the two groups of patients was that those who developed peritoneal eosinophilia had a significantly (P = .002) higher serum IgE concentration initially as well as throughout the period of observation.

Mycobacterium fortuitum peritonitis associated with continuous ambulatory peritoneal dialysis

Mycobacterium fortuitum has been isolated from skin and soft tissue lesions with increasing frequency. Rarely, however, has it been a documented cause of peritonitis in patients receiving continuous ambulatory peritoneal dialysis. We report here the second such case and discuss both the possibility of M. fortuitum or similar organisms as one cause of "sterile" peritonitis in this patient population and the in vitro antimicrobial susceptibility testing of such isolates.

Peritonitis in patients on continuous ambulatory peritoneal dialysis. A changing scene

Peritonitis is a serious and common complication in patients treated with continuous ambulatory peritoneal dialysis (CAPD). This work reports the experiences of this complication in 50 patients treated with CAPD for a total time of 844 months. 129 episodes were observed. Coagulase-negative staphylococci were found to be the causative organisms in 57% of the cases. Most episodes were acquired without any evident cause when CAPD was performed at home. Nine episodes were suspected to be the result of bacterial leakage through the intestinal wall. Six of them occurred in patients receiving corticosteroids. During the study period an increasing number of episodes of peritonitis were caused by organisms with multiple resistance to antibiotics. Thus, the microbiological spectrum in CAPD-related peritonitis must constantly be surveyed so that proper measures, e.g. regarding the choice of antibiotics used, can be taken when a change is observed.