Peritoneal Dialysis International, Vol. 27, pp. 214–218
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Printed in Canada. All rights reserved.
CORRESPONDENCE
Peritonitis Due to Multiresistant
Rhizobium radiobacter
Editor:
In January 2005, Lui and Lo reported the case of a
43-year-old Chinese end-stage renal disease patient in
a letter to the editor of this journal (1). [See also Com-
mentary by Miguela et al. in Perit Dial Int 2006; 26(1).]
The patient performed continuous ambulatory perito-
neal dialysis (PD) and developed a bacterial peritonitis
due to Rhizobium radiobacter (formerly Agrobacterium
radiobacter). The bacterial strain was sensitive to
cefuroxime and netilmicin, but relapses occurred within
a week of antibiotic therapy being discontinued. The
catheter had to be removed and the patient was switched
to a hemodialysis regimen.
Here we report the case of a 41-year-old Caucasian
patient with end-stage renal disease, maintained on
chronic PD, who developed peritonitis in which the in-
fectious organism was a multiresistant strain of Rhizo-
bium radiobacter. The patient had had no apparent
contact with soil or plant material. Only 1 day before,
diffuse abdominal tenderness set in and cloudy PD fluid
was noticed; an episode of gastroenteritis with severe
diarrhea had stopped. The PD catheter exit site was
clean; the patient had always been careful in perform-
ing the dialysis procedures. He had had only 1 previous
episode of bacterial peritonitis (Staphylococcus epi-
dermidis) during the previous 2 years. This time the or-
ganism was resistant to all beta-lactam compounds
except imipenem and the fourth-generation cepha-
losporin cefepime. The bacterium was also resistant to
trimethoprim-sulfamethoxazole and tobramycin, indif-
ferent to gentamicin, but sensitive to gyrase inhibitors
cipro- and levofloxacin. Treatment with intraperitoneal
cefepime plus oral ciprofloxacin lead to control of the
bacterial infection, indicated by a drop in PD fluid leu-
kocyte count from 17000/µL to <100/µL as well as
prompt relief of abdominal pain. The patient was not se-
verely ill, his C-reactive protein was negative, and his
serum leukocyte counts were normal throughout the
whole episode; therefore, he could be managed as an
outpatient. However, relapses occurred three times as
soon as antibiotic therapy was discontinued. A trial with
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Copyright © 2007 International Society for Peritoneal Dialysis
10 000 IU urokinase instillation overnight into the cath-
eter did not succeed in getting the catheter lumen clear.
Infection control was efficient after the peritoneal cath-
eter was surgically removed.
Although evidence in the literature is sparse — our
patient being the fifth reported case — a certain pat-
tern of PD peritonitis due to Rhizobium radiobacter may
be postulated.
This aerobic, oxidase-positive gram-negative bacte-
rium can be acknowledged as a motile (peritrichous fla-
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gella) biofilm inhabitant, which is potentially difficult to
eradicate since vancomycin resistance is obligate (2). The
genus Rhizobium (Agrobacterium) has long been known
as a plant pathogen causing crown gall and hairy root dis-
ease on a variety of vegetation. The species radiobacter is
serologically identical to Agrobacterium tumefaciens ex-
cept that it is not a plant pathogen. Rhizobium radiobacter
has been recovered from various human specimens.
Although none of the reported infections were con-
tracted in a hospital environment, all the strains were
resistant to at least one antibiotic agent. The highest
level of resistance being reported so far was seen in our
patient.
All other reported infections with Rhizobium radio-
bacter — apart from PD peritonitis — were associated with
artificial material such as central venous catheters (3,4),
prosthetic heart valves (endocarditis), and lens implants
(5); all of those had to be removed eventually. Therefore,
it may be wise in the case of a PD peritonitis with Rhizo-
bium radiobacter to make the decision for removal of the
peritoneal catheter sooner rather than later.
H. Rothe*
U. Rothenpieler
Kuratorium für Dialyse und Nierentransplantation
Bayern, Germany
*e-mail: hansjoerg.rothe@kfh-dialyse.de
REFERENCES
1. Lui SL, Lo WK. Agrobacterium radiobacter peritonitis in a
Chinese patient on CAPD [Letter]. Perit Dial Int 2005;
PDI MARCH 2007 – VOL. 27, NO. 2
25:95.
2. Young JM, Kuykendall LD, Martinez-Romero E, Kerr A,
Sawada H. A revision of Rhizobium Frank 1889, with an
emended description of the genus, and the inclusion of
all species of Agrobacterium Conn 1942 and Allorhizobium
undicola de Lajudie et al. 1998 as new combinations:
Rhizobium radiobacter, R. rhizogenes, R. rubi, R. undicola
and R. vitis. Int J Syst Evol Microbiol 2001; 51:89–103.
3. Paphitou NI, Rolston KV. Catheter-related bacteremia
caused by Agrobacterium radiobacter in a cancer patient:
case report and literature review. Infection 2003; 31:
421–4.
4. Landron C, Le Moal G, Roblot F, Grignon B, Bonnin A, Becq-
Giraudon B. Central venous catheter-related infection due
to Agrobacterium radiobacter: a report of 2 cases. Scand J
Infect Dis 2002; 34:693–4.
5. Namdari H, Hamzavi S, Peairs RR. Rhizobium (Agrobac-
terium) radiobacter identified as a cause of chronic endo-
phthalmitis subsequent to cataract extraction. J Clin
Microbiol 2003; 41:3998–4000.
Statin Treatment May Be Beneficial to
Both the Kidneys and the Heart
Editor:
The review by Shurraw and Tonelli (1) is detailed and
interesting; however, it lacks evidence to show whether
the beneficial effect of statins on renal function influ-
ences cardiovascular disease outcome. Here we briefly
report evidence that strengthens the conclusions of this
review (1).
In a post hoc analysis of the Greek Atorvastatin and
Coronary Heart Disease Evaluation (GREACE) Study (2),
we showed that, in dyslipidemic coronary heart disease
(CHD) patients (n = 800) with mildly impaired renal func-
tion (64% of the patients had stage 2 or 3 chronic kid-
ney disease), there was a decline in estimated glomerular
filtration rate (eGFR) over a period of 3 years, which sig-
nificantly increased the risk for cardiovascular disease
events [hazards ratio (HR) 1.10, 95% confidence inter-
val (CI) 1.03 – 1.21, p = 0.01 for every 5% reduction in
eGFR]. In contrast, those assigned to atorvastatin (n =
800, mean dose 24 mg/day), with the same chronic kid-
ney disease status, experienced a significant increase
in eGFR (12%, p < 0.0001), which contributed to a re-
duction in cardiovascular disease events (HR 0.84, 95%
CI 0.73 – 0.95, p = 0.003 for every 5% increase in eGFR).
These results were derived from a multivariate Cox pre-
dictive model that considered 19 univariate predictors
of CHD-related events.
Another GREACE post hoc analysis (3) suggested that
serum uric acid levels, with a strong and inverse asso-
CORRESPONDENCE
ciation with eGFR (3), are independent predictors of CHD
recurrent events. Atorvastatin treatment significantly
reduced serum uric acid levels in CHD patients, thus off-
setting an additional factor associated with CHD risk [HR
0.89, 95% CI 0.78 – 0.96, p = 0.03 for every 0.5 mg/dL
(30 µmol/L) reduction]. Moreover, among CHD patients
included in GREACE, those with metabolic syndrome ben-
efited more from statin treatment (HR 0.82, 95% CI
0.70 – 0.93, p < 0.001 for every 5% increase in eGFR in
multivariate analysis) in comparison with those without
metabolic syndrome (4).
These findings suggest that renal and cardiovascular
disease may progress in parallel. Statin treatment, pref-
erably implemented in the early stages of chronic kid-
ney disease, may be beneficial for both the kidneys and
the heart.
V.G. Athyros1*
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A. Karagiannis1
E.N. Liberopoulos2
M. Elisaf2
D.P. Mikhailidis3
Atherosclerosis and Metabolic Syndrome Units1
2nd Propedeutic Department of Internal Medicine
Aristotelian University
Hippocration Hospital, Thessaloniki
Department of Internal Medicine2
Medical School, University of Ioannina
Greece
Department of Clinical Biochemistry (Vascular
Disease Prevention Clinics)3
Royal Free Hospital
Royal Free and University College Medical School
London, United Kingdom
*e-mail: athyros@med.auth.gr
REFERENCES
1. Shurraw S, Tonelli M. Statins for treatment of dyslipidemia
in chronic kidney disease. Perit Dial Int 2006; 26:523–39.
2. Athyros VG, Mikhailidis DP, Papageorgiou AA, Symeonidis
AN, Pehlivanidis AN, Bouloukos VI, et al. The effect of
statins versus untreated dyslipidaemia on renal function
in patients with coronary heart disease. A subgroup analy-
sis of the Greek Atorvastatin and Coronary Heart Disease
Evaluation (GREACE) Study. J Clin Pathol 2004; 57:728–34.
3. Athyros VG, Elisaf M, Papageorgiou AA, Symeonidis AN,
Pehlivanidis AN, Bouloukos VI, et al; GREACE Study Col-
laborative Group. Effect of statins versus untreated
dyslipidemia on serum uric acid levels in patients with
coronary heart disease: a subgroup analysis of the GREek
215
CORRESPONDENCE
Atorvastatin and Coronary-heart-disease Evaluation
(GREACE) Study. Am J Kidney Dis 2004; 43:589–99.
4. Athyros VG, Mikhailidis DP, Liberopoulos EN, Kakafika AI,
Karagiannis A, Papageorgiou AA, et al. Effect of statin
treatment on renal function and serum uric acid levels and
their relation to vascular events in patients with coronary
heart disease and metabolic syndrome: a subgroup analy-
sis of the GREek Atorvastatin and Coronary heart disease
Evaluation (GREACE) Study. Nephrol Dial Transplant 2006
(23 September 2006; epub ahead of print, doi:10.1093/
ndt/gfl538).
Peritoneal Mucormycosis in
a Patient on CAPD
Editor:
Peritonitis is one of the most frequent complications
of long-term peritoneal dialysis and 10% – 15% of epi-
sodes are caused by fungal organisms. Candida species
account for the majority of episodes of fungal peritonitis
and non-Candida organisms such as Aspergillus and Mucor
have been uncommonly reported. We report a patient who
presented with two prior episodes of culture-negative
peritonitis; during the third episode, the peritoneal fluid
culture grew Rhizopus, species not identified.
A 62-year-old male, nondiabetic long-standing hyper-
tensive with stage 5 chronic kidney disease secondary
to hypertensive nephrosclerosis had been initiated on
continuous ambulatory peritoneal dialysis (CAPD)
4 years earlier. He was on the TwinBag system (Baxter
HealthCare, McGaw Park, Illinois, USA) doing four ex-
changes per day and doing well. He presented to us in
February 2005 with history of abdominal pain and cloudy
effluent. The peritoneal fluid count was 2090 cells/mm3,
with 90% polymorphs; however, the fluid culture was
sterile. The patient was treated with empirical vanco-
mycin and intraperitoneal ceftazidime for 14 days, with
which the abdominal symptoms and effluent cleared. He
was readmitted with a second episode of culture-nega-
tive peritonitis in March 2005 and was again empirically
treated. The patient had traveled and a breach in sterile
technique was demonstrated. He was admitted for the
third time in July 2005 with symptoms and signs of peri-
tonitis, with PD fluid counts of 800 cells/mm3 with 60%
polymorphs. Bacterial cultures and stain for acid-fast
bacilli were negative. Centrifuged PD fluid sediment re-
vealed broad aseptate fungal filaments on Calcofluor
staining (Sigma Chemicals, St. Louis, Missouri, USA), and
fungal culture of a large volume of peritoneal fluid re-
vealed growth of Rhizopus species (Figure 1). The Tenck-
hoff catheter was removed and the patient was switched
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MARCH 2007 – VOL. 27, NO. 2 PDI
Figure 1 — Fungal culture of peritoneal fluid (lacto-phenol blue
stain) shows broad aseptate hyphae of Rhizopus.
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over to hemodialysis and treated with parenteral lipo-
somal amphotericin B for 4 weeks (total of 1 g). In view
of an unhealthy looking peritoneum, peritoneal biopsy
was done at the time of catheter removal and revealed
dense submesothelial fibrosis with focal inflammatory
infiltrate, suggestive of fibrosing sclerosing peritonitis.
His general condition improved with treatment; however,
8 months later the patient died of a sudden cardiac event
at home.
Fungal organisms as cause of peritonitis, although
uncommon, are associated with significant morbidity
and mortality. The mortality rate of fungal peritonitis is
approximately 5% – 25%, whereas failure to resume CAPD
occurs in up to 40% of patients (1). Candida species are
the most common pathogens, accounting for 70% – 80%
of episodes of fungal peritonitis (1–3). Non-Candida or-
ganisms account for 20% – 30% of episodes; these in-
clude Aspergillus, Penicillium, Acremonium, Rhodotorula,
and Cryptococcus species. Except for isolated case re-
ports, peritonitis due to Rhizopus has rarely been re-
ported (4–6). The patients reported by Polo et al. (4)
and Monecke et al. (6) had a fulminant course despite
aggressive therapy. Our patient, similar to the one de-
scribed by Branton et al. (5), had shown an initial good
response to treatment but died of unrelated causes. Simi-
larly diffuse fibrinous peritonitis was seen on biopsy;
however, in contrast, no fungal invasion of the abdomi-
nal and bowel walls was noted.
Risk factors for the development of fungal peritonitis
include the use of steroids, prior antibiotic use within
3 months, frequent occurrence of bacterial peritonitis,
hyperglycemia, use of desferrioxamine, and hospitaliza-
tion (1,2). Our patient was not diabetic, but he had two
prior episodes of sterile peritonitis. Catheter removal
PDI MARCH 2007 – VOL. 27, NO. 2
remains an integral part of the management of fungal
peritonitis and a delay in catheter removal has been as-
sociated with greater mortality.
S. Nayak1
R. Satish1
Gokulnath1
J. Savio2
T. Rajalakshmi3
Department of Nephrology1
Department of Microbiology2
Department of Pathology3
St. John’s Medical College Hospital
Bangalore, India
*e-mail: nayak_shobhana@rediffmail.com
REFERENCES
1. Wang AYM, Yu AWY, Li PKT, Lam PK, Leung CB, Lai KN, et al.
Factors predicting outcome of fungal peritonitis in peri-
toneal dialysis: analysis of a 9-year experience of fungal
peritonitis in a single center. Am J Kidney Dis 2000; 36:
1183–92.
2. Bren A. Fungal peritonitis in patients on continuous am-
bulatory peritoneal dialysis. Eur J Clin Microbiol Infect Dis
1998; 17:839–43.
3. Prasad KN, Prasad N, Gupta A, Sharma RK, Verma AK,
Ayyagari A. Fungal peritonitis on continuous ambulatory
peritoneal dialysis. A single center Indian experience.
J Infect 2004; 48:96–101.
4. Polo JR, Luno J, Menarguez C, Gallego E, Robles R,
Hernandez P. Peritoneal mucormycosis in a patient receiv-
ing continuous ambulatory peritoneal dialysis. Am J Kid-
ney Dis 1989; 13:237–9.
5. Branton MH, Johnson SC, Brooke JD, Hasbargen JA. Peri-
tonitis due to Rhizopus in a patient undergoing continu-
ous ambulatory peritoneal dialysis. Rev Infect Dis 1991;
13:19–21.
6. Monecke S, Hochauf K, Gottschlich B, Ehricht R. A case of
peritonitis caused by Rhizopus microsporus. Mycoses 2006;
49:139–42.
The Sequelae of Chronic Infection Related
to Retained Cuffs of a Tenckhoff Catheter
Editor:
Debate still occurs about the question of surgical re-
moval of Tenckhoff catheters compared to the manual
“pull” technique. We present a 49-year-old male with
end-stage renal failure secondary to IgA nephropathy
CORRESPONDENCE
who was dialyzing via continuous ambulatory peritoneal
dialysis. Over 18 months he had four episodes of perito-
nitis, including on one occasion tunnelitis. His Tenck-
hoff catheter was removed on the last occasion by
manual traction, leaving both cuffs in situ. After switch-
ing to hemodialysis his urine output decreased progres-
sively and he became anuric.
In the months after removal of the catheter, he de-
veloped a midline sinus and underwent further explora-
tion; at this point the superficial cuff of the Tenckhoff
catheter was removed.
One year later, he again developed an anterior ab-
dominal wall collection inferior to the umbilicus in the
midline; this was incised and drained. Four days post
operatively he developed a collection lateral to the inci-
sion and underwent a further drainage. During this op-
eration the second deep Tenckhoff cuff was found and
excised.
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The wound was slow to heal and 9 months post opera-
tion he was noted to have granuloma at the operation
site, which was treated with corticosteroid cream. The
wound continued to ooze mucus and he developed what
was thought to be a sinus. He was placed on the waiting
list for further drainage and a sinogram was sought. This
showed an inferior tract that collected into a cavity in
the lower anterior abdominal wall (Figure 1); this was
thought to be the bladder.
At operation, this tract was opened and followed to
the cavity shown on the sinogram and was confirmed to
be the bladder. This was opened and a corrugated drain
placed in the bladder, exiting through the anterior ab-
dominal wall laterally. The original tract was closed with
PDS and nylon. Immediately post operatively he passed
Figure 1 — Preoperative sinogram with arrow indicating tract
to the bladder.
217
CORRESPONDENCE
blood urethrally. A bladder catheter was placed and the
bladder was irrigated with saline solution. While flush-
ing the bladder, irrigation fluid was noted to be expelled
from both the closed incision where the sinus had been
and the drain site, confirming that they were in conti-
nuity. He was unable to tolerate the urethral catheter
and it was removed 24 hours post procedure. The drain
was gradually withdrawn over the next 10 days and the
wound appeared to be healing well. Since then, the dis-
charge has returned.
We believe that failure to excise both cuffs at the origi-
nal setting has led to the formation of this vesico-cuta-
neous fistula — the first reported in the literature in a
patient with end-stage renal failure. Although cuffs can
be removed by continuous steady traction with good re-
sults (1), these patients had not had any recent infec-
tion at the time of removal. The deep cuff was retained
in all 31 of the patients in that study, while the superfi-
cial cuff was retained in 26. One superficial cuff was later
removed for local sepsis. Elkabir et al. (2) report a study
of 62 consecutive removals of Tenckhoff catheters by
traction: 15 developed local sepsis, with 10 of these hav-
ing had peritonitis prior to removal; 4 patients had deep
and superficial cuff infection, and 3 had superficial cuff
infection alone.
We believe that the tunnelitis and recurrent episodes
of peritonitis, combined with recurrent anterior abdomi-
nal wall surgery and cuff infection in a patient with poor
wound healing as a result of his end-stage renal failure,
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MARCH 2007 – VOL. 27, NO. 2 PDI
led to this fistula. Although both cuffs have been ex-
cised, we believe that the thick secretions produced by
his urinary tract are so highly viscous and of such low
volume that they fail to drain urethrally, leading to per-
sistence of the fistula.
This case illustrates the importance of surgical re-
moval of both cuffs in the presence of infection. When
Tenckhoff catheter removal is performed electively, with-
out the presence of infection, traction is a suitable
method.
R. Harvey
J. Marsh
E.S. Chemla*
South West Thames Renal Transplant Team
St. George’s Hospital
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London, United Kingdom
*e-mail: eric.chemla@stgeorges.nhs.uk
REFERENCES
1. Quiroga I M, Baboo R, Lord R H, Darby C R. Tenckhoff cath-
eters post-renal transplantation: the ‘pull’ technique?
Nephrol Dial Transplant 2001; 16:2079–81.
2. Elkabir J, Riaz A, Agarwal S, Williams G. Delayed compli-
cations following Tenckhoff catheter removal. Nephrol Dial
Transplant 1999; 14:1550–2.