Tuberculous Peritonitis in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis: Case Report and Review

A case of tuberculous peritonitis complicating continuous ambulatory peritoneal dialysis (CAPD) in a 37-year-old man who presented with fever, abdominal pain, and a malfunctioning Tenckhoff catheter is reported. The patient was initially treated for presumed bacterial peritonitis but remained febrile and had persistent abdominal pain and peritoneal fluid pleocytosis, despite broad-spectrum antibiotic therapy. Mycobacterium tuberculosis was isolated in a culture of peritoneal fluid, and the patient responded promptly to antituberculous therapy. More than 50 cases of tuberculous peritonitis complicating CAPD that have been reported in the English-language literature since the initial case was reported in 1980 are reviewed. The most common symptoms are fever (78%), abdominal pain (92%), and cloudy dialysate (90%); 76% of cases had a predominance of polymorphonuclear cells in peritoneal fluid. A smear for acid-fast bacilli or a culture was positive in 73% of cases. The peritoneal dialysis catheter was removed in 53% of cases, although this was rarely considered necessary for cure of tuberculosis. The attributable mortality rate is 15%, with the most significant factor being treatment delay (mean time from presentation to initiation of treatment, 6.74 weeks). We conclude that tuberculosis is an important diagnostic consideration for CAPD patients with peritonitis that is refractory to broad-spectrum antibiotics. Since its inception in 1976, continuous ambulatory peritoneal dialysis (CAPD) has been an effective treatment for end-stage renal disease (ESRD). In the United States, the treatment of »13% of patients requiring long-term renal substitution is managed with CAPD, whereas in some developing countries, 150% of the ESRD population is treated with CAPD [1]. The most common infectious complication of CAPD is bacterial peritonitis, which occurs an average of 1.3‐1.4 times per patientyear [2]. The usual microorganisms isolated in cases of peritonitis associated with CAPD include gram-positive skin commensal organisms (60%‐70%) and gram-negative aerobes (15%‐30%). Much less common are anaerobic organisms (1%‐5%), fungi (1%‐5%), and mycobacteria (!3%) [3‐6]. The first case of Mycobacterium tuberculosis‐complicated CAPD was reported in 1980 [7]. Since this initial case, there have been 50 others reported [8‐30]; we report the 52d. Since no one has previously reviewed 110‐15 cases, we provide a comprehensive review of all 52 reported cases.