NDT Advance Access originally published online on January 5, 2007
Nephrology Dialysis Transplantation 2007 22(5):1487; doi:10.1093/ndt/gfl736
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Vibrio vulnificus peritonitis after eating raw sea fish in a patient undergoing continuous ambulatory peritoneal dialysis (CAPD)
Email: drpdj{at}korea.comSir,
Vibrio vulnificus is an opportunistic pathogen that can cause serious, life-threatening infection in susceptible persons. Patients with chronic liver disease, alcoholism, immunodeficiencies, haemochromatosis or other iron overload states have increased susceptibility to infection by Vibrio species [1]. End-stage renal disease (ESRD) has been identified as a possible risk factor [2]. Only one case of V. vulnificus peritonitis developed after handling (but not ingestion) of sea fish, in a patient receiving continuous ambulatory peritoneal dialysis (CAPD) has been previously reported [3]. Here, we describe an episode of peritonitis in a CAPD patient caused by V. vulnificus after eating raw sea fish.
A 63-year-old man receiving CAPD for 5 years was admitted to our hospital with abdominal pain and cloudy peritoneal fluid. The underlying cause of his ESRD was diabetes mellitus and he had no history of peritonitis. He was a non-drinker and had no known history of liver disease. He was treated with erythropoietin, but had no iron therapy. Three days prior to presentation, he ate raw butterfish harvested from the Pacific coast; abdominal pain and vomiting started the next day. There was no history of trauma or exposure to seawater. On admission, the body temperature was 36.4°C, heart rate was 80 bpm, respiration rate was 20/min and blood pressure was 130/80 mmHg. There was tenderness in the lower abdomen, and the exit site of the peritoneal catheter was clean. The peripheral WBC count was 8130/mm3 and polymorphonuclear leukocytes (PMN) was 92.8%. The haemoglobin level was 6.2 g/dl, serum iron measurement showed the following values: iron 19 µg/dl, transferrin saturation 6.9%, ferritin 235.54 ug/l. The liver function test results were normal and viral markers for hepatitis B and C were negative. The peritoneal effluent contained >1000 WBCs/mm3, of which 91% were PMNs and 9% were lymphocytes. The patient was treated empirically with intraperitoneal cefazolin 1000 mg and tobramycin 40 mg. Soon after the start of empirical antibiotic therapy, the abdominal pain improved and the peritoneal effluent gradually cleared. Peritoneal effluent culture showed V. vulnificus sensitive to ampicillin, ceftriaxone, ciprofloxacin, piperacillin and imipenem, intermediate sensitivity to gentamicin, tobramycin and resistant to amikacin. Blood and stool culture showed no bacterial growth. After receiving the culture result, intraperitoneal cefazolin was discontinued, and oral doxycyclin was added to intraperitoneal tobramycin regimen. Antibiotic therapy was continued for 2 weeks; the patient recovered completely without complication.
V. vulnificus infection has been linked to three distinct syndromes: (i) primary septicaemia, (ii) wound infection and (iii) gastrointestinal illness [1]. Peritonitis in a patient receiving CAPD was previously reported and suggested that CAPD peritonitis may be another important clinical manifestation of Vibrio infection in patients undergoing CAPD [3–5].
In conclusion, patients with ESRD undergoing dialysis have an increased risk of infection with V. vulnificus. Furthermore patients receiving CAPD may present with CAPD peritonitis in addition to the previous clinical manifestations. These patients should be counselled to avoid raw seafood.
Conflict of interest statement. None declared.
Department of Internal Medicine
College of Medicine
Gyeongsang National University
Jinju
Republic of Korea
References
- Chiang SR and Chuang YC. (2003) Vibrio vulnificus infection: clinical manifestations, pathogenesis, and antimicrobial therapy. J Microbiol Immunol Infect 36:81–88.[Medline]
- Klontz KC, Lieb S, Schreiber M, Janowski HT, Baldy LM, Gunn RA. (1988) Syndromes of Vibrio vulnificus infections. Clinical and epidemiologic features in Florida cases, 1981–1987. Ann Intern Med 109:318–323.
[Abstract/Free Full Text] - Wong PN, Mak SK, Lo MW, et al. (2005) Vibrio vulnificus peritonitis after handling of seafood in a patient receiving CAPD. Am J Kidney Dis 46:e87–e90.[CrossRef][Web of Science][Medline]
- Ratanaraja N, Blackmore T, Byrne J, Shi S. (2005) Vibrio fluvialis peritonitis in a patient receiving continuous ambulatory peritoneal dialysis. J Clin Microbiol 43:514–515.
[Abstract/Free Full Text] - Taylor R, McDonald M, Russ G, Carson M, Lukaczynski E. (1981) Vibrio alginolyticus peritonitis associated with ambulatory peritoneal dialysis. Br Med J (Clin Res Ed) 283:275.
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