Clostridium difficile peritonitis in PD: Transmural migration or intestinal perforation?
Khan BSA, Reddy S, Zakhour S, Sallam O, and Shaban H. Clostridium difficile peritonitis in PD: Transmural migration or intestinal perforation? Am J Kidney Dis 2020; 75(4):595-596.
Am J Kidney Dis
Clostridium difficile (C.diff) causes colitis of varying severity and extra colonic infections are rarely seen. We present a case of C. diff peritonitis in a patient on peritoneal dialysis (PD) and sigmoid colonic perforation. An 85-year-old female with end stage renal disease on PD for 1 year presented with 1 day duration of abdominal pain. Upon presentation she was noted to be hypotensive with a BP 93/48mm Hg and a diffusely tender abdomen on exam. Labs revealed WBC 10.6 K/uL, Hgb 10.2g/dl, lactate 2.8 mmol/L. Computed tomography (CT) of the abdomen showed diverticulosis, mild colitis and free intraperitoneal air. PD fluid cell count was WBC 6310/ cu mm with a neutrophilic predominanace. Intraperitoneal vancomycin and cefepime were empirically initiated to treat PD associated peritonitis. Fluid cultures grew C.diff, Klebsiella oxytoca and Escherichia coli. Subsequently, she underwent an exploratory laparotomy which showed a full thickness ulcer in the sigmoid colon adjacent to the PD catheter. A wedge resection of the sigmoid colon and primary closure was performed and she was transitioned to hemodialysis. Dialysis patients have impaired immune responses and are frequently treated with antibiotics for infectious complications which increases their risk of nosocomial infections with C. diff. PD patients are inherently at risk of peritonitis due to the peritoneal cavity being accessible to the external environment as well as transmural migration of intestinal bacteria causing contamination. Diagnosing perforation could be delayed as CT findings of peritoneal air could be an expected finding in these patients. C.diff causing peritonitis as part of a polymicrobial isolate from PD fluid should alert the nephrologist to a possibility of a perforated viscus.