A 42 year‐old man with end‐stage renal disease on automated peritoneal dialysis (PD) presented with acute onset, diffuse, stabbing abdominal pain. Pain was worst in the epigastric region, and he had associated mild nausea, but no vomiting, fevers, sweats, or chills. He had diffuse abdominal tenderness to light palpation without guarding or rebound. No erythema or superficial skin changes were noted surrounding his Tenckhoff PD catheter. Laboratory testing revealed a WBC count of 13,700 with 84% neutrophils. A contrasted CT of the abdomen and pelvis showed multiple foci of free intra‐peritoneal air, free fluid in the para‐colic gutter, and subcutaneous soft tissue stranding within the anterior abdominal wall, suggestive of peritonitis. Peritoneal fluid analysis was noted as hazy, with 25 nucleated cells per mm3, of which 93 % were neutrophils. The patient was initially treated with intravenous cefotaxime and vancomycin for presumed PD catheter‐associated peritonitis. One day later, he was transitioned to intra‐peritoneal vancomycin and ceftazidime with significant clinical improvement. Peritoneal fluid gram stain was negative, but after 96 hours of growth, peritoneal fluid culture revealed Pasteurella multocida. On further questioning, the patient reported that 1 day prior to hospitalization, his pet cat was “playing” with his dialysis tubing during his daytime dwell. Additionally, his family had noted damp carpet near his dialysis supplies, suggestive of dialysis tubing puncture by his cat. He was discharged to complete a 2‐week course of intra‐peritoneal ceftazidime.
Peritonitis is an important potential complication of peritoneal dialysis. Morbidity is high, as PD catheter‐associated peritonitis is a leading cause for discontinuation of this dialysis modality. Hospitalists frequently care for patients on PD, therefore accurate diagnosis and management of this condition is paramount. Unlike peritonitis associated with continuous ambulatory PD, it is common for patients on automated PD to have peritonitis associated with < 100 WBC/mm3 on peritoneal fluid analysis. In these cases, diagnosis of PD‐associated peritonitis can be guided by history, exam, dialysate analysis showing >50% neutrophils, and cell culture results. Gram‐positive organisms account for most cases, with gram‐negative rods accounting for merely 15% of cases. P multocida is an uncommon cause of peritonitis in dialysis patients, previously reported in only 27 case reports since 1987; the vast majority of these cases involved exposure to household cats. P multocida is a gram‐negative coccobacillus that lives as normal upper respiratory tract flora in domesticated dogs, cats, and other animals. In many previous cases of Pasteurella peritonitis, the mechanism of infection was reported to be direct trauma or puncture of peritoneal dialysis tubing. P multocidais exquisitely sensitive to penicillins, with tetracyclines, fluoroquinolones and cephalosporins serving as appropriate alternatives.
Peritoneal dialysis patients are at risk for developing peritonitis. If strict hygiene practices are not maintained, patients with household pets, especially domesticated felines, can acquire Pasteurella multocidaperitonitis. Internists should consider this unusual cause of peritonitis when faced with PD catheter‐associated peritonitis, culture growth of a gram‐negative organism, and household cat exposure.
To cite this abstract:Brogan J, Ming D. Keep Your Paws Off My Catheter: An Unusual Cause of Peritoneal Dialysis‐Associated Peritonitis. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 358. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/keep-your-paws-off-my-catheter-an-unusual-cause-of-peritoneal-dialysisassociated-peritonitis/. Accessed March 28, 2020.