Abstract
Editor:
Although peritonitis is a common and major complication of continuous ambulatory peritoneal dialysis (CAPD), tuberculous peritonitis is reported infrequently in world literature, contributing only 1% – 2% of all cases of peritonitis (1). Tuberculous peritonitis is often diagnosed late in the course of the disease, resulting in undue morbidity and mortality. Routine laboratory methods are not sensitive in the early diagnosis of tubercular peritonitis, and identification by specific culture takes 4 – 6 weeks.
The usual clinical presentation of tuberculous peritonitis is abdominal pain, fever, and cloudy dialysate. In most patients, peritoneal fluid cell count is nonspecific, with neutrophilic predominance initially and possibly lymphocytic predominance later. We present an unusual case of tuberculous peritonitis that had neither clinical presentation nor peritoneal fluid cell count suggestive of tubercular peritonitis, but the peritoneal fluid smear and culture showed acid-fast bacilli (AFB).
The patient, a 65-year-old male who was a known case of chronic glomerulonephritis with end-stage renal disease, was initiated on CAPD in February 2000. He presented to our unit in June 2000 with complaints of anorexia and generalized weakness of 15 days’ duration. He had no history of fever, abdominal pain, or cough. On examination he was drowsy, dehydrated, and hypotensive. His chest examination revealed left basal rales and, on abdominal examination, there was no evidence of peritonitis. On investigation, his hemoglobin was 7.6 g/dL, total leukocyte count was 18 400/mm3, with predominantly neutrophils (91%). His blood urea was 72 mg/dL, serum creatinine was 4.0 mg/dL, serum albumin was 2.3 g/dL, SGPT was 49 U/L, and GGTP was 34 U/L. Chest x ray showed left basal consolidation. A respiratory physician advised bronchoscopy and bronchial wash for AFB smear. The patient did not cooperate with bronchoscopy. Ryles tube aspirate for AFB smear examined three times was positive. His peritoneal fluid was clear and cell count was 90/mm3, with differential count on 50 cells being 37 polymorphs and 13 lymphocytes. Out of curiosity, we sent 2 L peritoneal fluid for AFB smear and AFB culture and sensitivity. To our surprise, the peritoneal fluid AFB smear was positive. Peritoneal fluid AFB culture was followed up after 4 weeks and grew AFB. The patient was treated with ionotropes, antituberculous treatment, intravenous fluids, and steroids (thinking of adrenal crisis as the cause of hypotension), but his clinical condition deteriorated and he expired.
This patient had presented to our unit with nonspecific complaints and was found to have both pulmonary and peritoneal tuberculosis. A possibility in this patient is that the pulmonary Koch's had spread to the peritoneal cavity, suggesting dissemination of the tuberculosis, causing poor prognosis in this patient. Tubercular peritonitis has rarely been reported. The clinical picture of tubercular peritonitis in CAPD includes fever, abdominal pain, and cloudy dialysate, which is similar in bacterial and fungal peritonitis. The peritoneal fluid cell count is not helpful in diagnosing this condition as, although in nonuremic patients peritoneal fluid lymphocytosis is common (2), most patients on CAPD with tuberculous peritonitis show neutrophilic predominance (3), as was seen in our patient. Previous studies have shown that peritoneal fluid for AFB smear is not a sensitive test (3), although in our patient it was positive. Various different studies have shown that laparoscopy, laparotomy, and peritoneal biopsy are other ways of diagnosing tuberculous peritonitis (4). Three drugs for 9 – 12 months is adequate treatment for tuberculous peritonitis and, if diagnosed early, prognosis is good.
There is controversy regarding removal of Tenckhoff catheters in tuberculous peritonitis. There are studies suggesting that the catheter must be removed (5), while others have shown successful treatment of tuberculous peritonitis while continuing CAPD (6,7). Our patient had pulmonary tuberculosis proved by three samples of gastric aspirate positive for AFB, and had asymptomatic tuberculous peritonitis confirmed by positive peritoneal fluid AFB smear and culture. We wonder whether all patients on CAPD with pulmonary tuberculosis should be screened for tuberculous peritonitis, which might give a clue that the patient has disseminated tuberculosis; and whether in our patient, removal of the Tenckhoff catheter would have made any difference.