Peritoneal Dialysis International, Vol. 27, pp. 214–218 0896-8608/07 $3.00 + .

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CORRESPONDENCE

Peritonitis Due to Multiresistant 10 000 IU urokinase instillation overnight into the cath-
Rhizobium radiobacter eter did not succeed in getting the catheter lumen clear.
Infection control was efficient after the peritoneal cath-
eter was surgically removed.
Editor:
Although evidence in the literature is sparse — our
In January 2005, Lui and Lo reported the case of a
patient being the fifth reported case — a certain pat-
43-year-old Chinese end-stage renal disease patient in
tern of PD peritonitis due to Rhizobium radiobacter may
a letter to the editor of this journal (1). [See also Com-
be postulated.
mentary by Miguela et al. in Perit Dial Int 2006; 26(1).]
This aerobic, oxidase-positive gram-negative bacte-
The patient performed continuous ambulatory perito-
rium can be acknowledged as a motile (peritrichous fla-

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neal dialysis (PD) and developed a bacterial peritonitis
due to Rhizobium radiobacter (formerly Agrobacterium gella) biofilm inhabitant, which is potentially difficult to
radiobacter). The bacterial strain was sensitive to eradicate since vancomycin resistance is obligate (2). The
cefuroxime and netilmicin, but relapses occurred within genus Rhizobium (Agrobacterium) has long been known
a week of antibiotic therapy being discontinued. The as a plant pathogen causing crown gall and hairy root dis-
catheter had to be removed and the patient was switched ease on a variety of vegetation. The species radiobacter is
to a hemodialysis regimen. serologically identical to Agrobacterium tumefaciens ex-
Here we report the case of a 41-year-old Caucasian cept that it is not a plant pathogen. Rhizobium radiobacter
patient with end-stage renal disease, maintained on has been recovered from various human specimens.
chronic PD, who developed peritonitis in which the in- Although none of the reported infections were con-
fectious organism was a multiresistant strain of Rhizo- tracted in a hospital environment, all the strains were
bium radiobacter. The patient had had no apparent resistant to at least one antibiotic agent. The highest
contact with soil or plant material. Only 1 day before, level of resistance being reported so far was seen in our
diffuse abdominal tenderness set in and cloudy PD fluid patient.
was noticed; an episode of gastroenteritis with severe All other reported infections with Rhizobium radio-
diarrhea had stopped. The PD catheter exit site was bacter — apart from PD peritonitis — were associated with
clean; the patient had always been careful in perform- artificial material such as central venous catheters (3,4),
ing the dialysis procedures. He had had only 1 previous prosthetic heart valves (endocarditis), and lens implants
episode of bacterial peritonitis (Staphylococcus epi- (5); all of those had to be removed eventually. Therefore,
dermidis) during the previous 2 years. This time the or- it may be wise in the case of a PD peritonitis with Rhizo-
ganism was resistant to all beta-lactam compounds bium radiobacter to make the decision for removal of the
except imipenem and the fourth-generation cepha- peritoneal catheter sooner rather than later.
losporin cefepime. The bacterium was also resistant to
trimethoprim-sulfamethoxazole and tobramycin, indif- H. Rothe*
ferent to gentamicin, but sensitive to gyrase inhibitors U. Rothenpieler
cipro- and levofloxacin. Treatment with intraperitoneal
cefepime plus oral ciprofloxacin lead to control of the Kuratorium für Dialyse und Nierentransplantation
bacterial infection, indicated by a drop in PD fluid leu- Bayern, Germany
kocyte count from 17000/µL to <100/µL as well as
prompt relief of abdominal pain. The patient was not se- *e-mail: hansjoerg.rothe@kfh-dialyse.de
verely ill, his C-reactive protein was negative, and his
serum leukocyte counts were normal throughout the REFERENCES
whole episode; therefore, he could be managed as an
outpatient. However, relapses occurred three times as 1. Lui SL, Lo WK. Agrobacterium radiobacter peritonitis in a
soon as antibiotic therapy was discontinued. A trial with Chinese patient on CAPD [Letter]. Perit Dial Int 2005;

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PDI MARCH 2007 – VOL. 27, NO. 2 CORRESPONDENCE

25:95. ciation with eGFR (3), are independent predictors of CHD

2. Young JM, Kuykendall LD, Martinez-Romero E, Kerr A, recurrent events. Atorvastatin treatment significantly
Sawada H. A revision of Rhizobium Frank 1889, with an reduced serum uric acid levels in CHD patients, thus off-
emended description of the genus, and the inclusion of setting an additional factor associated with CHD risk [HR
all species of Agrobacterium Conn 1942 and Allorhizobium 0.89, 95% CI 0.78 – 0.96, p = 0.03 for every 0.5 mg/dL
undicola de Lajudie et al. 1998 as new combinations:
(30 µmol/L) reduction]. Moreover, among CHD patients
Rhizobium radiobacter, R. rhizogenes, R. rubi, R. undicola
and R. vitis. Int J Syst Evol Microbiol 2001; 51:89–103.
included in GREACE, those with metabolic syndrome ben-
3. Paphitou NI, Rolston KV. Catheter-related bacteremia efited more from statin treatment (HR 0.82, 95% CI
caused by Agrobacterium radiobacter in a cancer patient: 0.70 – 0.93, p < 0.001 for every 5% increase in eGFR in
case report and literature review. Infection 2003; 31: multivariate analysis) in comparison with those without
421–4. metabolic syndrome (4).
4. Landron C, Le Moal G, Roblot F, Grignon B, Bonnin A, Becq- These findings suggest that renal and cardiovascular
Giraudon B. Central venous catheter-related infection due disease may progress in parallel. Statin treatment, pref-
to Agrobacterium radiobacter: a report of 2 cases. Scand J erably implemented in the early stages of chronic kid-
Infect Dis 2002; 34:693–4. ney disease, may be beneficial for both the kidneys and
5. Namdari H, Hamzavi S, Peairs RR. Rhizobium (Agrobac- the heart.
terium) radiobacter identified as a cause of chronic endo-
phthalmitis subsequent to cataract extraction. J Clin
V.G. Athyros1*

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Microbiol 2003; 41:3998–4000.
A. Karagiannis1
E.N. Liberopoulos2
M. Elisaf2
Statin Treatment May Be Beneficial to D.P. Mikhailidis3
Both the Kidneys and the Heart
Atherosclerosis and Metabolic Syndrome Units1
Editor: 2nd Propedeutic Department of Internal Medicine
The review by Shurraw and Tonelli (1) is detailed and Aristotelian University
interesting; however, it lacks evidence to show whether Hippocration Hospital, Thessaloniki
the beneficial effect of statins on renal function influ- Department of Internal Medicine2
ences cardiovascular disease outcome. Here we briefly Medical School, University of Ioannina
report evidence that strengthens the conclusions of this Greece
review (1). Department of Clinical Biochemistry (Vascular
In a post hoc analysis of the Greek Atorvastatin and Disease Prevention Clinics)3
Coronary Heart Disease Evaluation (GREACE) Study (2), Royal Free Hospital
we showed that, in dyslipidemic coronary heart disease Royal Free and University College Medical School
(CHD) patients (n = 800) with mildly impaired renal func- London, United Kingdom
tion (64% of the patients had stage 2 or 3 chronic kid-
ney disease), there was a decline in estimated glomerular *e-mail: athyros@med.auth.gr
filtration rate (eGFR) over a period of 3 years, which sig-
nificantly increased the risk for cardiovascular disease REFERENCES
events [hazards ratio (HR) 1.10, 95% confidence inter-
val (CI) 1.03 – 1.21, p = 0.01 for every 5% reduction in 1. Shurraw S, Tonelli M. Statins for treatment of dyslipidemia
eGFR]. In contrast, those assigned to atorvastatin (n = in chronic kidney disease. Perit Dial Int 2006; 26:523–39.
800, mean dose 24 mg/day), with the same chronic kid- 2. Athyros VG, Mikhailidis DP, Papageorgiou AA, Symeonidis
ney disease status, experienced a significant increase AN, Pehlivanidis AN, Bouloukos VI, et al. The effect of
in eGFR (12%, p < 0.0001), which contributed to a re- statins versus untreated dyslipidaemia on renal function
duction in cardiovascular disease events (HR 0.84, 95% in patients with coronary heart disease. A subgroup analy-
sis of the Greek Atorvastatin and Coronary Heart Disease
CI 0.73 – 0.95, p = 0.003 for every 5% increase in eGFR).
Evaluation (GREACE) Study. J Clin Pathol 2004; 57:728–34.
These results were derived from a multivariate Cox pre- 3. Athyros VG, Elisaf M, Papageorgiou AA, Symeonidis AN,
dictive model that considered 19 univariate predictors Pehlivanidis AN, Bouloukos VI, et al; GREACE Study Col-
of CHD-related events. laborative Group. Effect of statins versus untreated
Another GREACE post hoc analysis (3) suggested that dyslipidemia on serum uric acid levels in patients with
serum uric acid levels, with a strong and inverse asso- coronary heart disease: a subgroup analysis of the GREek

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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
Figure 1 — Fungal culture of peritoneal fluid (lacto-phenol blue
Editor: stain) shows broad aseptate hyphae of Rhizopus.
Peritonitis is one of the most frequent complications

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of long-term peritoneal dialysis and 10% – 15% of epi- over to hemodialysis and treated with parenteral lipo-
sodes are caused by fungal organisms. Candida species somal amphotericin B for 4 weeks (total of 1 g). In view
account for the majority of episodes of fungal peritonitis of an unhealthy looking peritoneum, peritoneal biopsy
and non-Candida organisms such as Aspergillus and Mucor was done at the time of catheter removal and revealed
have been uncommonly reported. We report a patient who dense submesothelial fibrosis with focal inflammatory
presented with two prior episodes of culture-negative infiltrate, suggestive of fibrosing sclerosing peritonitis.
peritonitis; during the third episode, the peritoneal fluid His general condition improved with treatment; however,
culture grew Rhizopus, species not identified. 8 months later the patient died of a sudden cardiac event
A 62-year-old male, nondiabetic long-standing hyper- at home.
tensive with stage 5 chronic kidney disease secondary Fungal organisms as cause of peritonitis, although
to hypertensive nephrosclerosis had been initiated on uncommon, are associated with significant morbidity
continuous ambulatory peritoneal dialysis (CAPD) and mortality. The mortality rate of fungal peritonitis is
4 years earlier. He was on the TwinBag system (Baxter approximately 5% – 25%, whereas failure to resume CAPD
HealthCare, McGaw Park, Illinois, USA) doing four ex- occurs in up to 40% of patients (1). Candida species are
changes per day and doing well. He presented to us in the most common pathogens, accounting for 70% – 80%
February 2005 with history of abdominal pain and cloudy of episodes of fungal peritonitis (1–3). Non-Candida or-
effluent. The peritoneal fluid count was 2090 cells/mm3, ganisms account for 20% – 30% of episodes; these in-
with 90% polymorphs; however, the fluid culture was clude Aspergillus, Penicillium, Acremonium, Rhodotorula,
sterile. The patient was treated with empirical vanco- and Cryptococcus species. Except for isolated case re-
mycin and intraperitoneal ceftazidime for 14 days, with ports, peritonitis due to Rhizopus has rarely been re-
which the abdominal symptoms and effluent cleared. He ported (4–6). The patients reported by Polo et al. (4)
was readmitted with a second episode of culture-nega- and Monecke et al. (6) had a fulminant course despite
tive peritonitis in March 2005 and was again empirically aggressive therapy. Our patient, similar to the one de-
treated. The patient had traveled and a breach in sterile scribed by Branton et al. (5), had shown an initial good
technique was demonstrated. He was admitted for the response to treatment but died of unrelated causes. Simi-
third time in July 2005 with symptoms and signs of peri- larly diffuse fibrinous peritonitis was seen on biopsy;
tonitis, with PD fluid counts of 800 cells/mm3 with 60% however, in contrast, no fungal invasion of the abdomi-
polymorphs. Bacterial cultures and stain for acid-fast nal and bowel walls was noted.
bacilli were negative. Centrifuged PD fluid sediment re- Risk factors for the development of fungal peritonitis
vealed broad aseptate fungal filaments on Calcofluor include the use of steroids, prior antibiotic use within
staining (Sigma Chemicals, St. Louis, Missouri, USA), and 3 months, frequent occurrence of bacterial peritonitis,
fungal culture of a large volume of peritoneal fluid re- hyperglycemia, use of desferrioxamine, and hospitaliza-
vealed growth of Rhizopus species (Figure 1). The Tenck- tion (1,2). Our patient was not diabetic, but he had two
hoff catheter was removed and the patient was switched prior episodes of sterile peritonitis. Catheter removal

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remains an integral part of the management of fungal who was dialyzing via continuous ambulatory peritoneal
peritonitis and a delay in catheter removal has been as- dialysis. Over 18 months he had four episodes of perito-
sociated with greater mortality. nitis, including on one occasion tunnelitis. His Tenck-
hoff catheter was removed on the last occasion by
S. Nayak1 manual traction, leaving both cuffs in situ. After switch-
R. Satish1 ing to hemodialysis his urine output decreased progres-
Gokulnath1 sively and he became anuric.
J. Savio2 In the months after removal of the catheter, he de-
T. Rajalakshmi3 veloped a midline sinus and underwent further explora-
tion; at this point the superficial cuff of the Tenckhoff
Department of Nephrology1 catheter was removed.
Department of Microbiology2 One year later, he again developed an anterior ab-
Department of Pathology3 dominal wall collection inferior to the umbilicus in the
St. John’s Medical College Hospital midline; this was incised and drained. Four days post
Bangalore, India operatively he developed a collection lateral to the inci-
sion and underwent a further drainage. During this op-
*e-mail: nayak_shobhana@rediffmail.com eration the second deep Tenckhoff cuff was found and
excised.

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REFERENCES The wound was slow to heal and 9 months post opera-
tion he was noted to have granuloma at the operation
1. Wang AYM, Yu AWY, Li PKT, Lam PK, Leung CB, Lai KN, et al. site, which was treated with corticosteroid cream. The
Factors predicting outcome of fungal peritonitis in peri- wound continued to ooze mucus and he developed what
toneal dialysis: analysis of a 9-year experience of fungal was thought to be a sinus. He was placed on the waiting
peritonitis in a single center. Am J Kidney Dis 2000; 36: list for further drainage and a sinogram was sought. This
1183–92. showed an inferior tract that collected into a cavity in
2. Bren A. Fungal peritonitis in patients on continuous am- the lower anterior abdominal wall (Figure 1); this was
bulatory peritoneal dialysis. Eur J Clin Microbiol Infect Dis
thought to be the bladder.
1998; 17:839–43.
At operation, this tract was opened and followed to
3. Prasad KN, Prasad N, Gupta A, Sharma RK, Verma AK,
Ayyagari A. Fungal peritonitis on continuous ambulatory
the cavity shown on the sinogram and was confirmed to
peritoneal dialysis. A single center Indian experience. be the bladder. This was opened and a corrugated drain
J Infect 2004; 48:96–101. placed in the bladder, exiting through the anterior ab-
4. Polo JR, Luno J, Menarguez C, Gallego E, Robles R, dominal wall laterally. The original tract was closed with
Hernandez P. Peritoneal mucormycosis in a patient receiv- PDS and nylon. Immediately post operatively he passed
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 Figure 1 — Preoperative sinogram with arrow indicating tract
end-stage renal failure secondary to IgA nephropathy to the bladder.

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blood urethrally. A bladder catheter was placed and the led to this fistula. Although both cuffs have been ex-
bladder was irrigated with saline solution. While flush- cised, we believe that the thick secretions produced by
ing the bladder, irrigation fluid was noted to be expelled his urinary tract are so highly viscous and of such low
from both the closed incision where the sinus had been volume that they fail to drain urethrally, leading to per-
and the drain site, confirming that they were in conti- sistence of the fistula.
nuity. He was unable to tolerate the urethral catheter This case illustrates the importance of surgical re-
and it was removed 24 hours post procedure. The drain moval of both cuffs in the presence of infection. When
was gradually withdrawn over the next 10 days and the Tenckhoff catheter removal is performed electively, with-
wound appeared to be healing well. Since then, the dis- out the presence of infection, traction is a suitable
charge has returned. method.
We believe that failure to excise both cuffs at the origi-
nal setting has led to the formation of this vesico-cuta- R. Harvey
neous fistula — the first reported in the literature in a J. Marsh
patient with end-stage renal failure. Although cuffs can E.S. Chemla*
be removed by continuous steady traction with good re-
sults (1), these patients had not had any recent infec- South West Thames Renal Transplant Team
tion at the time of removal. The deep cuff was retained St. George’s Hospital
in all 31 of the patients in that study, while the superfi-

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London, United Kingdom
cial cuff was retained in 26. One superficial cuff was later
removed for local sepsis. Elkabir et al. (2) report a study *e-mail: eric.chemla@stgeorges.nhs.uk
of 62 consecutive removals of Tenckhoff catheters by
traction: 15 developed local sepsis, with 10 of these hav- REFERENCES
ing had peritonitis prior to removal; 4 patients had deep
and superficial cuff infection, and 3 had superficial cuff 1. Quiroga I M, Baboo R, Lord R H, Darby C R. Tenckhoff cath-
infection alone. eters post-renal transplantation: the ‘pull’ technique?
We believe that the tunnelitis and recurrent episodes Nephrol Dial Transplant 2001; 16:2079–81.
of peritonitis, combined with recurrent anterior abdomi- 2. Elkabir J, Riaz A, Agarwal S, Williams G. Delayed compli-
nal wall surgery and cuff infection in a patient with poor cations following Tenckhoff catheter removal. Nephrol Dial
wound healing as a result of his end-stage renal failure, Transplant 1999; 14:1550–2.

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