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 ~ Introduction
 ~ Case Report
 ~ Discussion
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  Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 36  |  Issue : 4  |  Page : 600-602
 

An unusual case of unresolving tunnel infection in a patient on continuous ambulatory peritoneal dialysis


1 Department of Nephrology, Institue of Kidney Disease Urology and Organ Transplantation, Madras Medical Mission, Chennai, Tamil Nadu, India
2 Department of Microbiology, Madras Medical Mission, Chennai, Tamil Nadu, India

Date of Web Publication18-Mar-2019

Correspondence Address:
Dr. Georgi Abraham
Institute of Kidney Disease Urology and Organ Transplantation, Madras Medical Mission, Mogappair, Chennai - 600 037, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmm.IJMM_18_425

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 ~ Abstract 

Atypical mycobacteria remain a rare cause of peritoneal dialysis catheter-related tunnel infection (TI) and poses serious risk because of the resistant nature to most antibiotic therapy. Non-tubercular mycobacterial infections lead to chronicity requiring peritoneal dialysis catheter removal. We report an 82-year-old male, with diabetic nephropathy who had a coinfection with Staphylococcus hominis and Mycobacterium abscessus who presented with pus discharge at exit site and TI. He was treated with relocation of the extraperitoneal part of the catheter with a new exit site without catheter removal and multidrug mycobacterial therapy.


Keywords: Coinfection, Mycobacterium abscessus, peritoneal dialysis tunnel infection


How to cite this article:
Marzuk S M, Rohit A, Nagarajan P, Nzana V, Katuraga VM, Parthasarathy R, Mathew M, Abraham G. An unusual case of unresolving tunnel infection in a patient on continuous ambulatory peritoneal dialysis. Indian J Med Microbiol 2018;36:600-2

How to cite this URL:
Marzuk S M, Rohit A, Nagarajan P, Nzana V, Katuraga VM, Parthasarathy R, Mathew M, Abraham G. An unusual case of unresolving tunnel infection in a patient on continuous ambulatory peritoneal dialysis. Indian J Med Microbiol [serial online] 2018 [cited 2019 May 21];36:600-2. Available from: http://www.ijmm.org/text.asp?2018/36/4/600/254398



 ~ Introduction Top


Continuous ambulatory peritoneal dialysis (CAPD) is a form of renal replacement therapy for patients with end-stage kidney disease. Older patients with multiple comorbidities who desire home therapy is an indication for CAPD. Diabetes mellitus and old age produce senescence of the immune system and predispose patients to catheter-related infections. Peritoneal dialysis and in particular CAPD are associated with a high risk of peritonitis, tunnel infection (TI) and catheter exit-site infection (ESI).[1] Catheter ESI and TI are a major source of morbidity. ESI and TIs increase the risk of catheter loss, peritonitis and overall PD technique failure.[2] Majority of the ESIs are caused by Gram-positive organisms and can be successfully treated by appropriate antimicrobial therapy for a period of 2–3 weeks without catheter loss.[3] Non-tuberculous mycobacterium (NTM) is a very rare cause of ES and TI and requires catheter removal for management along with antimicrobial therapy. Mycobacterium abscessus is a rapidly growing NTM and rarely causes TI among PD patients. It is usually difficult to treat M. abscessus because of its resistant nature to most of the antibiotics.[4] TI may present as erythema, oedema or tenderness over the subcutaneous site but is often clinically occult, as shown by ultrasound studies.[5] TI usually occurs in the presence of an ESI but rarely occurs alone. Here, we described an early onset of NTM in an 82-year-old T2D patient on CAPD.


 ~ Case Report Top


An 82-year-old male, with hypertension, T2D and chronic obstructive pulmonary disease, who was a smoker with Stage V chronic kidney disease (CKD), was started on CAPD since April 2018 after implanting swan neck double-cuff permanent PD catheter.

In September 2018, he presented with complaints of discharge and redness around the peritoneal dialysis catheter exit site (ES). Swab from the ES grew Staphylococcus hominis for which he was started on quinolones as per sensitivity. Ultrasonographic screening of the catheter tunnel showed no evidence of infection. After 2 weeks on antibiotics, he came with persistent mucopurulent discharge from the ES. He had no history of fever and abdominal pain, and PD effluent was clear. There were redness and mild sprouting of flesh around the ES. There were no warmth and tenderness around the ES. Investigations showed WBC of 6100 cells/mm 3 (polymorph – 79.1%, lymphocyte – 14.7%, monocyte – 4.4% and eosinophil – 1.6%), Hb – 10.5 g/dl, platelet – 187,000/cu.mm, total protein – 5.1 g/dl and serum albumin – 2.7 g/dl. Ultrasonography showed subcutaneous tunnel collection, and the ES was explored under general anaesthesia which confirmed TI extending from ES to anterior rectus sheath with sparing of the inner cuff [Figure 1].
Figure 1: Ultrasonography showing necrotic tissue in the tunnel surgical repositioning of catheter

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The tract with unhealthy granulation tissue was excised in total. The extraperitoneal portion of the PD catheter was rerouted medially, and new ES was created away from the previous exit. He was continued on CAPD without interruption. The excised exit tissue showed acid-fast bacilli (on Ziehl–Neelsen stain and Auramine O stain). Histopathological examination showed features suggestive of acute on chronic inflammation. Following this, he was started on four drug antituberculous regimens (HRZE). Bacterial cultures did not yield any growth. Automated liquid TB culture was put on the MGIT 360 (Beckton Dickenson). The MGIT 360 flagged positive after 2 weeks of incubation. Following sterility check, the organism was tested by the MPT64 antigen detection by immunochromatography for the presence of Mycobacterium tuberculosis and found to be negative. The isolate was then grown on Lowenstein–Jensen media and identified by Vitek MS (nioMeriuex, France) as Mycobacterium abscesses. The antituberculous drugs were switched over to oral clarithromycin 500 mg twice daily, oral ofloxacin 400 mg once daily and amikacin 500 mg intravenous injection once in 2 days. He is on the above regimen for 7 weeks, and the skin shows two discharging sinuses [Figure 2] without peritonitis. The patient has been advised catheter removal and reimplantation of a new catheter concurrently through a new entry point. The patient has not made a decision for the procedure, and he is being followed up with ultrasound of tunnel every 2 weeks to see the progress of therapy.
Figure 2: Discharging sinus tract from previous tunnel

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 ~ Discussion Top


Peritonitis remains a leading complication of PD which accounts for 18% of the infection-related mortality in PD patients. An ESI is defined by the presence of purulent drainage, with or without erythema of the skin at the catheter-skin interface. Pericatheter erythema without purulent discharge is sometimes an early indication of infection but can also be a simple skin reaction, particularly in a recently placed catheter or after trauma to the catheter.[5] ESI and TI are associated with an increased risk of peritonitis. The incidence of ESI in PD patients ranges from 0.05 to 1.02 episodes per patient-year. The incidence of ESIs is seen anywhere between one episode in 27.3 patients' months to one episode in 41.9 patients' months.[6] The diagnosis of TI is mainly based on clinical suspicion and ultrasound examination. The extent of involvement of the subcutaneous PD catheter tract is a critical factor in the development of peritonitis.[6]

The most common organism associated with ESI and TI is Staphylococcus aureus and Pseudomonas aeruginosa. The incidence of mycobacterial infections has grown rapidly over the last few years. In particular, non-tuberculous mycobacterial infections, especially those caused by Mycobacterium fortuitum and Mycobacterium chelonae, are becoming highly prevalent. However, peritoneal catheter ESIs are very rare.[7]

M. abscessus is a rapidly growing NTM that requires 1–3 weeks to grow and was named after its ability to produce deep subcutaneous abscess.[8] These mycobacteria have an affinity for the dermis and the subcutaneous area, and in a non-immunosuppressed patient, protective factors within the peritoneum contain the infection, which is not the case with CKD.[9]

Infections due to M. abscessus are usually refractory to medical treatment because this organism is intrinsically resistant to many of the currently available antituberculous drugs and antibiotics. The drugs currently recommended for the treatment of M. abscessus infections are a combination therapy of clarithromycin with one aminoglycoside and one other injectable drug such as cefoxitin or imipenem. Macrolides are the only active oral antibiotic against M. abscessus.[10] Treatment modalities also include removal of the infected catheter and simultaneous replacement with a new catheter. Close interaction between the clinical microbiologist and nephrologists is the key to successful diagnosis and treatment of patients.

We identified ten cases of ESIs and/or TIs due to M. abscessus in the literature of which, only four cases had TIs.[4],[11],[12],[13] All the patients with M. abscessus infection ended up in catheter removal, and they were restarted on haemodialysis [Table 1]. Our patient presented with persistent discharge, and his PD catheter was rerouted and started on empirical antibiotic therapy. M. abscessus was identified on tissue culture. He responded well to the treatment and continued on peritoneal dialysis. If there has been a delay in diagnosis, the infection would have progressed to peritonitis, And catheter removal would have been the only option.
Table 1: Outcome of reported peritoneal dialysis tunnel infection with Mycobacterium abscessus

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Our patient had two swab cultures that grew bacteria but did not respond to antibiotics. That prompted us to do a tissue culture that isolated the M. abscessus which highlighted the fact that NTM and M. tuberculosis cannot be isolated from swabs. Hence, there should be a high realm of suspicion of NTM in a patient with persistent ESI/TI, despite appropriate antibiotic therapy in case of non-responsiveness. The only method to obtain microbiological evidence is through tissue culture from the wall of the cavity, which is very difficult to obtain and takes 3 weeks to isolate from culture leading to delayed treatment, which makes clinical diagnosis the best option. Appropriate culture media should be used or routine culture should be prolonged following discussion with the microbiologist. Early diagnosis and prompt treatment with combination antibiotics may help to prevent the catheter loss.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 ~ References Top

1.
Akoh JA. Peritoneal dialysis associated infections: An update on diagnosis and management. World J Nephrol 2012;1:106-22.  Back to cited text no. 1
    
2.
Swartz RD. Exit-site and catheter care: Review of important issues. Adv Perit Dial 1999;15:201-4.  Back to cited text no. 2
    
3.
Szeto CC, Li PK, Johnson DW, Bernardini J, Dong J, Figueiredo AE, et al. ISPD catheter-related infection recommendations: 2017 update. Perit Dial Int 2017;37:141-54.  Back to cited text no. 3
    
4.
Renaud CJ, Subramanian S, Tambyah PA, Lee EJ. The clinical course of rapidly growing nontuberculous mycobacterial peritoneal dialysis infections in Asians: A case series and literature review. Nephrology (Carlton) 2011;16:174-9.  Back to cited text no. 4
    
5.
Georgi A, Evgeije S, Anthony A, Sharron I, Stephen IV, Raymond EM, et al. Natural history of exit-site infection (ESI) in patients on continuous ambulatory peritoneal dialysis (CAPD). Perit Dial Int 1988;8:211-6.  Back to cited text no. 5
    
6.
Prasad N, Gupta A, Mathew M, Abraham G. Access-related complications in peritoneal dialysis in developing countries. Adv Ren Replace Ther 2002;9:144-8.  Back to cited text no. 6
    
7.
Dunmire RB 3rd, Breyer JA. Nontuberculous mycobacterial peritonitis during continuous ambulatory peritoneal dialysis: Case report and review of diagnostic and therapeutic strategies. Am J Kidney Dis 1991;18:126-30.  Back to cited text no. 7
    
8.
Nessar R, Cambau E, Reyrat JM, Murray A, Gicquel B. Mycobacterium abscessus: A new antibiotic nightmare. J Antimicrob Chemother 2012;67:810-8.  Back to cited text no. 8
    
9.
Rohit A, Abraham G. Peritoneal dialysis related peritonitis due to Mycobacterium spp.: A case report and review of literature. J Epidemiol Glob Health 2016;6:243-8.  Back to cited text no. 9
    
10.
Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F, et al. An official ATS/IDSA statement: Diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med 2007;175:367-416.  Back to cited text no. 10
    
11.
Lo MW, Mak SK, Wong YY, Lo KC, Chan SF, Tong GM, et al. Atypical mycobacterial exit-site infection and peritonitis in peritoneal dialysis patients on prophylactic exit-site gentamicin cream. Perit Dial Int 2013;33:267-72.  Back to cited text no. 11
    
12.
Ellis EN, Schutze GE, Wheeler JG. Nontuberculous mycobacterial exit-site infection and abscess in a peritoneal dialysis patient. A case report and review of the literature. Pediatr Nephrol 2005;20:1016-8.  Back to cited text no. 12
    
13.
Hibi A, Kasugai T, Kamiya K, Kamiya K, Ito C, Kominato S, et al. Peritoneal dialysis-associated catheter infection caused by Mycobacterium abscessus in an elderly patient who was successfully treated with catheter removal. CEN Case Rep 2017;6:175-9.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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