Abstract
Editor:
Certain underlying medical conditions, such as diabetes, diverticulitis, and corticosteroid therapy, may predispose patients on continuous ambulatory peritoneal dialysis (CAPD) to the development of peritonitis. It has also been suggested that gynecologic infection may be a source of peritoneal infection. We report a case of recurrent peritonitis that remitted after removal of an indwelling intrauterine device (IUD).
A 48-year-old woman, married and mother of 2 children, started CAPD in 1995 because of renal failure due to membranoproliferative glomerulonephritis. She had received a copper-containing IUD several years before. Renal transplantation was performed in April 1996. CAPD was reinitiated in March 1999 after failure of the transplant due to chronic rejection. The allograft was not removed. The patient had regular menses, and bloody peritoneal effluent related directly to menstruation was noted on some separate occasions. Ultrasound examination of the pelvis did not reveal ovarian cysts or intra-abdominal lesions. In March 2001, the patient consulted because of pain at the allograft site and fever. A rejection reaction was suspected and low-dose corticosteroids were added to her treatment. The fever and pain disappeared within 3 – 5 days, and corticosteroid therapy was continued.
In August 2001, she was admitted for CAPD peritonitis. Cultures revealed a combination of Serratia sp and Escherichia coli. Treatment with ciprofloxacin cleared the infection. The patient did well until a second episode of peritonitis with Citrobacter sp 1 month later. Another episode with E. coli and enterococci in October 2001 was treated with intraperitoneal vancomycin and amikacin. At this time, an abdominal scan did not show intra-abdominal pathology, and there was neither a tunnel nor an exit-site infection. Dialysate cleared quickly but a few days later, while still on antibiotic therapy, the peritoneal effluent became cloudy. A new culture showed enterococci again. During this time, the patient did not complain of genital symptoms; however, on gynecological examination performed the day before the reappearance of cloudy dialysate, she had a scant vaginal discharge. The IUD was removed and cultured, revealing a combination of enterococci and E. coli. Treatment was continued and peritonitis cleared quickly. The patient has remained free of further peritonitis since the IUD was removed.
Generally, it is assumed that polymicrobial infections develop when bowel organisms from diverticular abscess or perforation contaminate the peritoneum. But micro-organisms could also reach the abdominal cavity in a retrograde direction through female internal organs (1,2). Although retrograde menstruation occurs in most menstruating women (3), secondary contamination and even infection of the peritoneal fluid are rarely described and are usually related to invasive procedures (4-7).
Pelvic inflammatory disease and, at times, severe infectious disease are well-known complications of IUDs; the risk is highest during the first month after insertion or under immunosuppressed conditions such as dialysis or corticosteroid therapy. We feel that our patient developed peritonitis secondary to an infected IUD. She had past anamnestic evidence of retrograde menstruation; thus, retrograde flow of infection was the likely cause of this peritonitis. The growth of E. coli and enterococci on the IUD demonstrates its infectivity; the prompt remission after removal of the IUD supports peritonitis being due to it and not to CAPD.
Only two cases of peritonitis secondary to an IUD in female CAPD patients have been previously described (2,4). It is noteworthy that those patients, like ours, had prior episodes of bloody dialysate effluent indicating retrograde menstruation. The recent course of corticosteroid therapy in our patient may have made her vulnerable to peritoneal contamination. For any female CAPD patient we should always pay attention to performance of a detailed gynecological evaluation if recurrent peritonitis and/or polymicrobial infection appears, especially if the patient is using an IUD.