Abstract: PUB192
The "Silent" Threat: Group G Streptococcus Peritonitis in Peritoneal Dialysis
Session Information
Category: Dialysis
- 802 Dialysis: Home Dialysis and Peritoneal Dialysis
Authors
- Lau, Lucinda, Rowan University Cooper Medical School, Camden, New Jersey, United States
- Benincasa, Stefano, Rowan University Cooper Medical School, Camden, New Jersey, United States
- Nash, Rachel S., Rowan University Cooper Medical School, Camden, New Jersey, United States
Introduction
Peritoneal dialysis (PD) is a therapy for patients with end-stage renal disease (ESRD). PD carries an increased risk of peritonitis, often secondary to poor technique. A small subset of patients may present with “silent” peritonitis, or peritonitis in the absence of fever and abdominal pain, making diagnosis and treatment challenging. Identification of a causative organism can be an added barrier further delaying care.
Case Description
A 95-year-old female with a history of ESRD on PD presented with two days of progressive fatigue, confusion, and lower leg pain and swelling.
On exam, a shallow, ulcerated wound with purulent drainage was found on the left lateral leg. Laboratory testing was significant for leukocytosis and group G streptococcus (GGS) grown on blood cultures. Treatment with vancomycin and ceftriaxone did not yield significant improvement, prompting investigation of PD dialysate as a potential source. The patient was afebrile with persistent leukocytosis and no clinical signs of peritonitis. Peritoneal fluid analysis revealed increased cellularity with neutrophilic predominance suggesting peritonitis despite negative cultures. Intraperitoneal ceftriaxone and prophylactic fluconazole were added to the patient’s nightly PD dwell.
Repeat blood and PD fluid cultures were negative. However, the patient was ultimately transitioned to comfort measures before passing shortly thereafter.
Discussion
Commonly, PD peritonitis is caused by gram positive organisms, such as Staphylococcus and Streptococcus species, with the ability to create biofilms on nonbiologic surfaces. GGS is a rare cause of peritonitis, more commonly present on the skin and in the urogenital and gastrointestinal tracts. Still, research investigating its effect on the presentation of peritonitis is sparse.
It is important to remain cognizant of PD peritonitis in patients receiving PD therapy even in the absence of classic symptomatology. Risk factors such as advanced age, dementia, altered mentation from sepsis, or uncommon organisms may create an atypical presentation, delaying diagnosis and treatment. High rates of morbidity in peritonitis with concomitant bacteremia make early treatment even more crucial.