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Commuted tomography of the abdomen and pelvis performed without intravenous contrasts. The perintoneal dialysis catheter is seen traversing subcutaneous tissue and entering the perintoneal cavity on the left side of the abdomen.
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A young man with end-stage renal disease from focal segmental glomerulosclerosis has been on peritoneal dialysis (PD) for more than 4 years. He has not had any major complications. He is a low average transporter. He uses the cycler to complete 4 night-time exchanges of 2.5L of 2.5% dialysate, each exchange lasting approximately 120 minutes. He performs 1–2 additional day exchanges of approximately 2 L each lasting about 150 minutes. He has about 800 mL per day of residual urine output. He is compliant to treatments and medications. His blood pressure is well controlled and dry weight has been stable at about 100 kg for some time. He denies any drain pain, shortness of breath, or leg edema. He uses gentamicin cream daily at this exit site to reduce risk of infection.He presents to a clinic with some pain and fullness around his PD catheter that has slowly developed over last week. On further questioning, he had noted a small excoriation about 3 cm below his PD catheter exit site for almost 2 weeks. It had been quite pruritic initially, but since resolved and scabbed over.He denies fevers, chills, nausea, abdominal pain, or other skin exanthem. He denies any break in aseptic technique. He does endorse mild constipation. On exam, there is no exit site leakage or erythema or purulence. There is a rather immobile area of fullness in the subcutaneous tissue just below the exit site, with a small healing excoriation at its center. A sample of PD fluid is taken and is fairly clear without sediment. Polymorphonuclear cell count is 80 and there are 500 RBCs present. A computed tomography scan of abdomen and pelvis is performed and representative images are shown:
Submit your diagnosis to see full explanation.
Imaging studies in this patient show a PD catheter surrounded by a fluid collection as it traverses the soft tissue prior to entering the peritoneum. The clinical history, exam and diagnostic data confirm the diagnosis of a substantial PD catheter tunnel abscess. Furthermore, the PD catheter tip is misplaced in the left lower quadrant. There is significant stool burden as well.
Answer: E
PD catheter tunnel infections usually arise from exit site infections. Staphylococcus aureus and Pseudomonas aeruginosa are implicated in many exit site infections and empiric antibiotics should cover these organisms. Local S. aureus and P. aeruginosa sensitivity profiles should be taken into consideration as empiric agents are chosen. If a tunnel infection is suspected, then ultrasonography may be useful to look for associated fluid collection.
An exit site or tunnel infection that does not respond to antibiotic therapy within a week generally will require PD catheter removal and change of exit site positive. PD catheter tunnel infection with peritonitis or with tunnel site abscess requires prompt removal of the catheter and peritoneal rest while the infection resolves. The patient will need to transition to hemodialysis. Needless to say, empiric antibiotics to coverage common gram-positive and gram-negative pathogens are indicated pending further cultures and sensitivities.
This patient likely developed this abscess from the peri-catheter abrasion that he suffered, and not so much from poor exit site care. Proper exit site care, adherence to sterile PD technique, and patient and provider vigilance for uncommon sources of contamination are all integral tools for minimizing infectious complications in PD.
References
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Li PK, Szeto CC, Piraino B, et al. International Society for Peritoneal Dialysis. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int 2010;30:393-423.
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Vychytil A, Lorenz M, Schneider B, et al. New criteria for management of catheter infections in peritoneal dialysis patients using ultrasonography. J Am Soc Nephrol 1998;9:290-296.
This case was prepared by Kevin T. Harley, MD, Assistant Clinical Professor of Medicine, Division of Nephrology & Hypertension, at the University of California in Irvine.
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