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An Unusual Presentation of Vaginal Leakage in a Peritoneal Dialysis Patient

Article in Peritoneal Dialysis International · November 2010

DOI: 10.3747/pdi.2009.00229 · Source: PubMed

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A 39-year-old woman with IgA nephropathy was com- menced on nocturnal intermittent PD in 2007 after a failed renal transplant and recurrent vascular access

• problems. To improve dialysis adequacy, daytime ex-

changes were needed 1 year later following an episode

• f uremic pericarditis. The patient presented in 2010

with her first episode of peritonitis. Analysis of the peri- toneal effluent demonstrated a white cell count of 730/mm3, with 59% neutrophils. The patient was treated initially with intraperitoneal cefazolin and ceftazidime. Gram stain revealed the presence of gram-negative ba- cilli: cefazolin was discontinued. Resolution of perito- neal fluid cloudiness was noted within 3 days of initiation of antibiotics but the identity of the gram- negative organism remained obscure over the ensuing 3 weeks. The organism was subsequently identified as a Capno- cytophaga species. Further questioning revealed the pa- tient had two cats as household pets. There was no history of animal bites but the patient admitted to hav- ing been regularly licked on the face by her two favorite domestic cats. The patient was fond of kissing her cats and seldom wore a mask during the PD exchange proce-

• dure. She also reported fair adherence to proper hand

washing after contact with her cats. The cats were al- lowed in her room except while she was performing PD

• exchanges. She could not exclude contamination by cat

fur and dander because she switched on an electric fan heater at the time of the exchange procedure on the evening prior to developing peritonitis. In light of the patient’s lifestyle, her exposure to cats is considered the primary source of her Capnocytophaga infection. The prolonged period required to identifying Capno- cytophaga species is related to the slow growth of these thin gram-negative rods that are facultative anaerobes. The name of the organism derives from its property as the “eater of carbon dioxide” because Capnocytophaga species grow best in a carbon dioxide-enriched atmo-

• sphere. Both C. canimorsus and C. cynodegmi are part of

the normal flora of dogs and cats. Peritonitis infection with Capnocytophaga species has been reported in only 3 PD patients (1–3). Of the three cases reported in the literature, two were highly suspicious of cat-associated

• peritonitis. One patient on nocturnal automated PD re-

ported sleeping with his domestic cat, which had punc- tured the PD tubing (1), whereas the other had frequent visits by the neighbor’s cat, which he occasionally fed (2). In addition to the relatively well-known transmission

• f Pasteurella multocida from cats (4), we believe that

Capnocytophaga infection should also be considered in PD patients in close contact with cats.

DISCLOSURES

The authors do not have any conflicts of interest to declare. K.M. Chow* W.F. Pang C.C. Szeto P.K.T. Li Division of Nephrology Department of Medicine and Therapeutics Prince of Wales Hospital Chinese University of Hong Kong Hong Kong *e-mail: Chow_Kai_Ming@alumni.cuhk.net

REFERENCES

• 1. Chadha V, Warady BA. Capnocytophaga canimorsus peri-

tonitis in a pediatric peritoneal dialysis patient. Pediatr Nephrol 1999; 13:646–8.

• 2. Pers C, Tvedegaard E, Christensen JJ, Bangsborg J. Capno-

cytophaga cynodegmi peritonitis in a peritoneal dialysis

• patient. J Clin Microbiol 2007; 45:3844–6.
• 3. Esteban J, Albalate M, Caramelo C, Reyero A, Carriazo MA,

Hernandez J, et al. Peritonitis involving a Capnocytophaga

• sp. in a patient undergoing continuous ambulatory peri-

toneal dialysis. J Clin Microbiol 1995; 33:2471–2.

• 4. Mat O, Moenens F, Beauwens R, Rossi C, Muniz-Martinez

MC, Mestrez F, et al. Indolent Pasteurella multocida peri- tonitis in a CCPD patient. 25 years of “cat-bite peritoni- tis”: a review. Perit Dial Int 2005; 25:88–90.

doi:10.3747/pdi.2010.00070

An Unusual Presentation of Vaginal Leakage in a Peritoneal Dialysis Patient

Editor: Dialysate leaks in peritoneal dialysis (PD) are clini- cally important because they may cause fluid retention and a consequent decrease in fluid removal and clear-

• ance. There are few reports on the diagnosis and man-

agement of vaginal leakage in PD. Recurrent and refractory peritonitis may lead to the formation of sub- compartments in the peritoneal cavity as a result of ad-

• hesions. We present here a case of a patient in whom

recurrent peritonitis led to formation of a subcompart- ment in the peritoneal cavity, which was then compli- cated by intractable vaginal leakage.

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Figure 1 — Peritoneography demonstrates leakage through fallopian tubes (a) and the contrast agent shows accumula- tion of the dialysis solution in a subcompartment (b); Tenck- hoff catheter (c).

A 27-year-old woman had been on continuous ambu- latory PD treatment with 2 L 4 times daily for 15 months. Despite eight peritonitis episodes, she refused to trans- fer to hemodialysis. Her PD catheter was changed twice because of these recurrent peritonitis episodes. Six months after her most recent catheter change, she pre- sented with a 4-week history of dialysate leakage through her vagina. Physical examination was normal, as was the abdominal ultrasound. Abdominal CT showed thickening of the visceral and parietal peritoneum. Con- trast peritoneography was conducted in order to inves- tigate the vaginal leakage (Figure 1). The dialysate did not diffuse homogenously throughout the cavity, collect- ing instead in a subcompartment and then passing out through the uterine cavity. The patient was switched to hemodialysis after removal of the PD catheter. Peritonitis may be complicated by peritoneal thick- ening, loculated fluid collections, abscesses, and adhe- sions (1). Extraperitoneal dialysate leakage is a well-recognized complication of PD and is related to in- creased abdominal pressure (2). It usually occurs in the anterior abdominal wall or the pelvis (3) and recurs in as many as 5% of PD patients (4). Vaginal leakage is much less common (5–7). It may be due to erosion of the cath- eter through the peritoneum lining the pouch of Dou- glas or to leakage of dialysate through the fallopian tubes (8). A related complication is capture of the PD catheter by the fimbriae of the fallopian tube (7). In our patient, vaginal leakage may have been related to cap- ture of the PD catheter by the fallopian tube fimbriae in a subcompartment of the peritoneal cavity, which had formed due to adhesions related to recurrent peritoni-

• tis. Radiologic methods are important in the diagnosis
• f vaginal leakage. In our case, peritoneal thickening

was revealed by abdominal CT. Peritoneography with contrast confirmed the accumulation of dialysis solution in a subcompartment that was communicating with the vagina. This mechanism of vaginal leakage has not previously been described.

DISCLOSURES

The authors did not receive financial support.

• M. Ceri1*
• M. Altay 2
• S. Unverdi1
• I. Kurultak3
• M. Duranay1

Department of Nephrology1 Department of Internal Medicine2 Ankara Education and Research Hospital Department of Nephrology3 Ankara University Faculty of Medicine Ankara, Turkey *e-mail: tscer@yahoo.com

REFERENCES

• 1. Cakir B, Kirbas I, Cevik B, Ulu EM, Bayrak A, Coskun M.

Complications of continuous ambulatory peritoneal dialy- sis: evaluation with CT. Diagn Interv Radiol 2008; 14: 212–20.

• 2. Bargman JM. Complications of peritoneal dialysis related

to increased intraabdominal pressure. Kidney Int 1993; 40:75–80.

• 3. Leblanc M, Ouimet D, Pichette V. Dialysate leaks in peri-

toneal dialysis. Semin Dial 2001; 14:50–4.

• 4. Tzamaloukas AH, Gibel LJ, Eisenberg B, Goldman RS, Kanig

SP, Zager PG, et al. Early and late peritoneal dialysate leaks in patients on CAPD. Adv Perit Dial 1990; 6:64–71.

• 5. Coward RA, Gokal R, Wise M, Mallick NP, Warrell D. Perito-

nitis associated with vaginal leakage of dialysis fluid in continuous ambulatory peritoneal dialysis. Br Med J 1982; 284:1529.

• 6. Whiting MA, Smith NI, Agar JW. Vaginal peritoneal dialy-

sate leakage per fallopian tubes. Perit Dial Int 1995; 15:85.

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• 7. Macallister RJ, Morgan SH. Fallopian tube capture of

chronic peritoneal dialysis catheters. Perit Dial Int 1993; 13:74–6.

• 8. Caporale N, Perez D, Alegre S. Vaginal leak of peritoneal

dialysis liquid. Perit Dial Int 1991; 11:284–5.

doi:10.3747/pdi.2009.00229

An Unusual Case of Vaginal Leak in a Patient on Peritoneal Dialysis

Editor: Continuous ambulatory peritoneal dialysis (CAPD) is associated with very few complications, which include abdominal hernia, peritonitis, processus vaginalis, pleu- ral leakage, and those related to the catheter exit site (1). Few cases have been reported of complications asso- ciated with leakage of peritoneal fluid. Although the in- cidence of leakage of peritoneal fluid varies, it is described in up to 5% of patients on CAPD (2–4). We re- port a case of a woman who experienced vaginal leakage during CAPD. A 74-year-old woman with end-stage renal failure due to hypertensive nephropathy had been on CAPD for 2 years. She reported a 3-month history of abdominal pain accompanied by vomiting and fever of 37.5°C. She under- went hernia repair and was transferred to hemodialysis (HD). There was no previous history of peritonitis. The symptoms appeared a few days after starting HD and con- tinued after restarting peritoneal dialysis (PD). The peri- toneal effluent was clear. Urine and peritoneal fluid cultures were negative. Blood test showed C-reactive pro- tein 284 ng/mL, ferritin 579 mg/dL, and hypoalbumin- emia (albumin 1.7 g/dL); leukocyte count was normal. One month later the patient presented loss of clear liquid after infusion of the dialysis solution. As vaginal or uri- nary leakage was suspected, additional tests were ordered. Abdominal ultrasound study showed collection around the pericatheter tip and a gas bubble inside the uterine cavity. Peritoneal scintigraphy was done with technetium-99m (Figure 1). To determine whether the leakage was urinary or vaginal we used a urinary cath- eter and measured the quantity of marker that passed from the peritoneal cavity. The counts obtained were 20883620 from the vagina and 78379 from the bladder, which are compatible with a vaginal fistula. The fistula was repaired and a uterine rupture was found during surgery. This was sutured and the patient was trans- ferred to HD. On restarting PD 4 weeks later, there was no further vaginal leakage. Due to discomfort during dialy- sate infusion, the patient opted for definitive HD. Several types of peritoneal fluid leakage have been described in patients on PD, such as processus vaginalis and pleural and urinary leakage (4). However, their in- cidence is very low. Our patient presented vaginal leak- age with no genital tract abnormalities. There are two main mechanisms resulting in vaginal leakage. One is di- alysate leakage through the fallopian tube and then the uterus and vagina, and the other is a fistula between the uterus and the peritoneal cavity produced after surgery (4). The fact that our patient presented vaginal leakage immediately after repair of an umbilical hernia, as well as the uterine rupture found later, suggests the second

• mechanism. It is unknown whether the uterine rupture
• ccurred during surgery or was associated with catheter

perforation because of its mobilization near the uterine surface after surgery. The differential diagnosis was between urinary incon- tinence and urinary leakage. The former was less prob- able because the leakage disappeared when the patient stopped PD. The results of the peritoneal scintigraphy made the second possibility unlikely. Treatment consists of rupture repair and transfer to HD, either temporarily or definitively. One patient was suc- cessfully treated with PD after leakage repair (4), as in

• ur case, although our patient eventually preferred HD.

In conclusion, vaginal leakage in a patient on PD, al- though uncommon, is a complication associated with this mode of dialysis. This complication should be suspected in women with genital leakage and previous abdominal surgery.

DISCLOSURES

The authors do not have any conflicts of interest to declare.

• C. Cobelo
• S. Ros*

Figure 1 — Peritoneal scintigraphy with technetium-99m dem-

• nstrating marker uptake in the uterus and vagina after 3 hours
• f performing the scan. Tc-99m was diluted in the dialysis so-

lution and administered into the peritoneal cavity through the peritoneal catheter.

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