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NDT Plus Advance Access originally published online on September 18, 2008
NDT Plus 2009 2(1):59-62; doi:10.1093/ndtplus/sfn150
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© The Author [2008]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

White tide

Dipa Chatterjee1, Laurie R. Solomon1, Uwe Roesler2, Amanda Barnes3 and Alexander Woywodt1

1 Renal Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
2 Institute of Animal and Environmental Hygiene, Free University Berlin, Berlin, Germany
3 Consultant Microbiologist, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK

Correspondence: Correspondence and offprint requests to: Alexander Woywodt, Renal Unit, Lancashire Teaching Hospitals NHS Trust, Royal Preston Hospital, Sharoe Green Lane, Preston, PR2 9HT, UK. Tel: +44-1772-524629; Fax: +44-1772-522162; E-mail: Alex.Woywodt{at}lthtr.nhs.uk

Key Words: differential diagnosis • peritoneal dialysis • peritonitis • prototheca • rare organisms

Received for publication August 19, 2008. Accepted for publication August 21, 2008.


   Introduction
Top
 Introduction
Case
 Discussion
 Teaching points
 References
 
Infectious problems, such as exit-site infection and peritonitis, are common complications of peritoneal dialysis (PD). Peritonitis is usually bacterial and either caused by gram-positive organisms as a sequel to handling errors or by gram-negative bacteria as a result of underlying gastrointestinal pathology. Several antibiotic guidelines have been formulated. We present a case of PD peritonitis that provided an interesting challenge after cultures grew a rare organism. We discuss the case with an emphasis on rare organisms and the factors associated with these infections.


   Case
Top
 Introduction
 Case
Discussion
 Teaching points
 References
 
A 35-year-old female patient on peritoneal dialysis (PD) presented with abdominal pain and turbid dialysis fluid in August 2004 after several previous episodes of PD peritonitis.

She had been diagnosed with medullary cystic disease on the basis of a renal biopsy and reached end-stage renal disease in February 1998 when CAPD was initiated. An inguinal hernia was repaired in September 2000, and an umbilical hernia was repaired in 2001. She had two episodes of peritonitis due to coagulase-negative staphylococci in 2002 and another two episodes, again due to staphylococci, in April and December 2003. All of these episodes were believed to be due to handling errors, and the patient underwent re-training. She presented, again, with peritonitis in April 2004, and cultures grew coagulase-negative staphylococci. A new catheter was inserted in April 2004. In spite of the new catheter, she presented again in May 2004 with another episode of gram-positive PD peritonitis. Plans were made to switch the patient to haemodialysis while she sustained yet another episode of PD peritonitis in August 2004, with turbid peritoneal fluid and a PD fluid leukocyte count of 246/µl. She was admitted and treated with intra-peritoneal vancomycin and oral ciprofloxacin as per unit protocol at the time. Cultures grew coagulase-negative staphylococci and another organism that was initially identified as yeast. The patient continued to be clinically well with clear PD fluid. Oral fluconazole and flucytosine were administered, and the PD catheter was removed; the patient was switched to haemodialysis. The cultures were finally identified as Prototheca spec, a rare achlorophyllic infectious algae.


   Discussion
Top
 Introduction
 Case
 Discussion
Teaching points
 References
 
PD peritonitis is defined as the presence of at least two out of the following three criteria: (1) fever, abdominal pain or tenderness, (2) presence of >100/µl white blood cells per millilitre of dialysate fluid and (3) identification of organisms in the dialysate. Most cases of PD peritonitis are straightforward and either gram positive due to handling error or gram negative due to intra-abdominal pathology. Some cases remain culture negative and a variety of non-infectious causes need to be considered as well [1].

PD peritonitis can also be due to uncommon organisms (Table 1) [2]. Among the gram-positive cocci, Streptococcus is an uncommon pathogen in PD peritonitis and associated with severe disease [2]. Streptococcus pneumoniae is sometimes seen with the presence of an intrauterine device (IUD) [2]. Gram-positive rods are rarely isolated from PD fluid, usually after the patient had some form of contact with soil [2]. Neisseria gonorrhoeae is a gram-negative coccus that is associated with gonorrhoea and passage of the organism through the fallopian tube into the PD fluid. Contact with animals seems to be a particular risk factor for acquisition of gram-negative rods from the genus Pasteurella. P. multocida has been reported in conjunction with dog and cat exposure [3]. PD peritonitis due to P. pneumotropica has been reported after contamination of the PD tubing by a pet hamster [4]. PD peritonitis due to Pseudomonas often requires removal of the PD catheter. Other Pseudomonas species, such as P. putida, are uncommon [2]. Rare gram-negatives include Alcaligenes and Flavimonas, which are associated with exposure to contaminated water. Gram-negative rods (Vibrionaceae) have been reported in PD peritonitis in conjunction with houseplant spray and scuba diving [2]. Mixed gram-negatives in culture usually signal a serious intra-abdominal problem, and urgent imaging is warranted with a low threshold for further investigations, surgical exploration and removal of the PD catheter. Finally, PD peritonitis due to anaerobes is extremely rare [5].


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  		Table 1 Rare micro-organisms as a cause of PD peritonitis [2]

 
Mycobacteria have also been reported to cause PD peritonitis. The diagnosis can be delayed due to the slow growth rate of some mycobacterial species, and these organisms can be overlooked unless adequate culture media are used [6]. Fungal peritonitis is overwhelmingly due to Candida species. Unusual species of fungi in PD peritonitis are listed in Table 1. The management of fungal peritonitis is beyond the scope of our little teaching point and reviewed elsewhere [7]. Suffice to say that a variety of anti-fungal agents are used but that removal of the PD catheter is often required. Finally, viral PD peritonitis is very rare and cytomegalovirus has been described in anecdotal reports.

Algae or algae-like organisms are rarely isolated in PD peritonitis. The genus Prototheca denotes achlorophyllic algae [8] that reproduce asexually. Five species have been recognized, P. stagnora, P. ulmea, P. blaschkeae, P. zopfii and P. wickerhamii. The last three have been implicated in human infections. Prototheca species are found in soil, marine water and sewage. Protothecosis in animals is well documented [8] and affects cows, cats, dogs, deer, salmon, carp and flying foxes [8]. Mastitis is common in cows whereas clinical syndromes in dogs include skin disease, colitis and eye involvement. Bovine mastitis usually leads to udder atresia, and canine systemic protothecosis is often fatal.

Clinical syndromes in humans include cutaneous disease, wound infection and, rarely, systemic disease. Bursitis has also been described, as has been intestinal disease. Systemic protothecosis is exceedingly rare [9]. Mohabeer and colleagues described a 75-year-old patient with myasthenia gravis who developed algaemia due to Prototheca wickerhamii from a skin lesion on his hand [10]. The clinical spectrum of human protothecosis is reviewed in great detail elsewhere [11].

The diagnosis of protothecosis rests on cultures of these rare organisms on a mycological culture medium. Macroscopically, the cultures can be mistaken for Candida although their microscopic features have been described as unique and characteristic [9] (Figures 1 and 2). The cell membrane of these organisms is glucosamine deficient; they stain with periodic acid-Schiff (PAS) and Gomori-methenamine silver (GMS). The diagnostic features of Prototheca species in culture are discussed elsewhere [8]. Therapeutic recommendations are difficult, given that the number of human cases is so small. Prototheca species are believed to be sensitive to amphothericin B and the azoles whereas flucytosin is believed to be ineffective [8]. Gentiana violet, polymixin B and a variety of other preparations have been advocated for topical treatment. Others have emphasized that removal of infected tissue is very effective in localized disease [9].


Figure 1
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  		Fig. 1 Prototheca in culture. The figure shows Prototheca zopfii (isolated from another patient) on Sabouraud-dextrose agar after 72 h at 37°C.

 


Figure 2
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  		Fig. 2 Prototheca zopfii (isolated from another patient) stained with Lactophenole-cotton-blue. The arrow denotes a sporangiospore, a characteristic feature of asexual reproduction in these organisms, within a mature cell (sporangium).

 
To our knowledge, we describe the fifth patient with PD peritonitis due to Prototheca in the literature. O’Connor and colleagues in 1986 reported a 41-year-old woman on CAPD who required removal of her PD catheter after peritonitis with Prototheca wickerhamii that was unresponsive to amphotericin B. [12]. In this case, another attempt to place a Tenckhoff catheter 3 months after the episode proved unsuccessful due to dense intra-peritoneal adhesions. Gibb and co-workers saw another PD patient with Prototheca wickerhamii peritonitis and removed the PD catheter [13]. Sands et al. described the case of a 72-year-old PD patient with peritonitis due to Prototheca wickerhamii who needed PD catheter removal and was subsequently treated with intravenous amphotericin and oral doxycycline [14]. This patient died of post-operative complications, and dense adhesions were found at autopsy. Finally, Pérez Melón reported on a 36-year-old PD patient with Prototheca peritonitis who also needed removal of the catheter [15]. Most cases of human protothecosis are believed to originate from contact with dirty water [9]. When asked, our patient could only attribute the infection to the fact that water pipes and sanitation in her home were in need of modernization. She had no pets, and she could not recall any other exposure to water or sewage.

It is difficult to draw any conclusions from these reports as to the treatment of Prototheca peritonitis in PD patients. A variety of anti-microbial agents, such as amphothericin [14], the azoles and doxycyclin [14], have been described to be effective in human and animal protothecosis while contact with a reference laboratory and resistance testing are mandatory. However, in algal PD peritonitis, removal of the catheter was required in the majority of patients. In this regard, algal peritonitis appears to have a clinical course not unlike fungal PD peritonitis. Previous reports also report a high incidence of intra-peritoneal adhesions after algal peritonitis, thus precluding further attempts at PD.

Infectious problems are common in PD. The case presented here took an unexpected turn when the microbiologist observed a smooth, creamy-white organism that eventually proved to be Prototheca wickerhamii. Algae sometimes make the headlines after an algal bloom in coastal waters, and the term ‘red tide’ has been used. In truth, this phenomenon is not associated with tidal movement. Some red tides are associated with the production of toxins and wildlife mortality. To us, this case provided a first encounter with ‘white tide’ and algae in the peritoneal cavity as well as an opportunity to review the differential diagnosis of PD peritonitis due to uncommon organisms.


   Teaching points
Top
 Introduction
 Case
 Discussion
 Teaching points
References
 

(i) PD peritonitis is usually gram positive due to handling error or gram negative due to intra-abdominal disease. However, a broad variety of rare organisms are sometimes isolated as well.
(ii) These rare organisms may be uncommon bacteria, mycobacteria, fungi, algae or viruses.
(iii) Many of these organisms are acquired through contact with animals, soil or water. This underpins the importance of teaching good hand hygiene during PD training.
(iv) Algae are a rare cause of PD peritonitis. The clinical characteristics of algal PD peritonitis seem to resemble those of fungal disease.
(v) A variety of antimicrobial agents may be effective, but removal of the PD catheter is often required.

Conflict of interest statement. None declared.


   References
Top
 Introduction
 Case
 Discussion
 Teaching points
 References
 

  1. de Freitas DG, Gokal R. Sterile peritonitis in the peritoneal dialysis patient. Perit Dial Int (2005) 25:146–151.[Abstract/Free Full Text]
  2. von Graevenitz A, Amsterdam D. Microbiological aspects of peritonitis associated with continuous ambulatory peritoneal dialysis. Clin Microbiol Rev (1992) 5:36–48.[Abstract/Free Full Text]
  3. Antony SJ, Oglesby KA. Peritonitis associated with Pasteurella multocida in peritoneal dialysis patients—case report and review of the literature. Clin Nephrol (2007) 68:52–56.[Web of Science][Medline]
  4. Campos A, Taylor JH, Campbell M. Hamster bite peritonitis: pasteurella pneumotropica peritonitis in a dialysis patient. Pediatr Nephrol (2000) 15:31–32.[CrossRef][Web of Science][Medline]
  5. Seriburi V, Reynolds J. Enteric peritonitis caused by Clostridium perfringens in peritoneal dialysis. Conn Med (2007) 71:281–283.[Medline]
  6. Rho M, Bia F, Brewster UC. Nontuberculous mycobacterial peritonitis in peritoneal dialysis patients. Semin Dial (2007) 20:271–276.[CrossRef][Web of Science][Medline]
  7. Lui SL, Chan TM, Lai KN, et al. Tuberculous and fungal peritonitis in patients undergoing continuous ambulatory peritoneal dialysis. Perit Dial Int (2007) 27(Suppl_2):S263–S266.[Abstract/Free Full Text]
  8. Pore RS. Prototheca and chlorella species. In: Topley and Wilsons Microbiology and Microbial Infections—Collier L, Balows A, Sussmann M, eds. (1997) 9th ed. New York: McGraw-Hill.
  9. Thiele D, Bergmann A. Protothecosis in human medicine. Int J Hyg Environ Health (2002) 204:297–302.[CrossRef][Web of Science][Medline]
  10. Mohabeer AJ, Kaplan PJ, Southern PM Jr, et al. Algaemia due to Prototheca wickerhamii in a patient with myasthenia gravis. J Clin Microbiol (1997) 35:3305–3307.[Abstract/Free Full Text]
  11. Kantrow SM, Boyd AS. Protothecosis. Dermatol Clin (2003) 21:249–255.[CrossRef][Web of Science][Medline]
  12. O’Connor JP, Nimmo GR, Rigby RJ, et al. Algal peritonitis complicating continuous ambulatory peritoneal dialysis. Am J Kidney Dis (1986) 8:122–123.[Web of Science][Medline]
  13. Gibb AP, Aggarwal R, Swainson CP. Successful treatment of Prototheca peritonitis complicating continuous ambulatory peritoneal dialysis. J Infect (1991) 22:183–185.[CrossRef][Web of Science][Medline]
  14. Sands M, Poppel D, Brown R. Peritonitis due to Prototheca wickerhamii in a patient undergoing chronic ambulatory peritoneal dialysis. Rev Infect Dis (1991) 13:376–378.[Web of Science][Medline]
  15. Perez Melon C, Camba M, Tinajas A, et al. Prototheca Wickerhami peritonitis in patients on peritoneal dialysis. Nefrologia (2007) 27:81–82.[Web of Science][Medline]
  16. Ohtani H, Imai H, Komatsuda A, et al. Hemoperitoneum due to acute cytomegalovirus infection in a patient receiving peritoneal dialysis. Am J Kidney Dis (2000) 36:E33.[CrossRef][Medline]

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This Article
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