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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44; </span></p><p class="elsevierStylePara">Peritoneal infections are a serious complication in peritoneal dialysis and can affect the clinical state of the patient and technique viability&#46;<span class="elsevierStyleSup">1</span> Gram positive bacteria are most frequently involved &#40;coagulase negative S<span class="elsevierStyleItalic">taphylococcus </span>&#91;40&#37;-60&#37;&#93;&#44; <span class="elsevierStyleItalic">Staphylococcus aureus </span>&#91;10&#37;-20&#37;&#93; and <span class="elsevierStyleItalic">Streptococcus</span> &#91;10&#37;-20&#37;&#93;&#41;&#46; Of all peritonitis&#44; 5&#37;-20&#37; are due to gram negative organisms&#46; Other germs&#44; which represent less than 5&#37; of cases&#44; are other bacteria&#44; fungi and protozoa&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">There are not many cases of <span class="elsevierStyleItalic">Listeria monocytogenes</span> peritonitis published in the literature&#44; and they generally affect immunocompromised patients&#46;<span class="elsevierStyleSup">2-12</span></p><p class="elsevierStylePara">We present the case of a patient undergoing peritoneal dialysis due to heart failure resistant to diuretics&#46; This is the first case of <span class="elsevierStyleItalic">Listeria monocytogenes </span>infection in the peritoneum in our hospital&#46;</p><p class="elsevierStylePara">We present a 64-year-old man who underwent an operation for tetralogy of Fallot when he was younger&#46; He later developed a severe right heart failure and eventually became resistant to diuretics&#46; This caused him to be admitted to hospital on several occasions for anasarca and acute renal failure&#46; He was rejected for a heart transplant because he had severe pulmonary hypertension&#46; Given this situation&#44; he was entered onto a peritoneal ultrafiltration programme &#40;May 2006&#41;&#44; having a single night exchange of 2l of icodextrin&#46;</p><p class="elsevierStylePara">The patient arrived at the emergency department with abdominal pain&#44; moderate diarrhoea and cloudy peritoneal drainage fluid&#46; He did not complain of fever&#44; vomiting or focal neurological or infectious signs&#46; He had no family history of food borne diseases and he was not aware of having made any mistakes with the dialysis technique&#44; which would have caused the equipment to become unsterile&#46; This patient had already suffered two other peritonitis&#44; with negative peritoneal fluid culture&#46; He was treated successfully with wide spectrum antibiotics &#40;vancomycin and ceftazidime&#41;&#44; recovering without any major problems&#46;</p><p class="elsevierStylePara">When he was admitted&#44; signs of distension and pain were noted upon abdominal palpation&#46; Analytical tests showed&#58; leukocyte count&#58; 8900&#47;&#181;l&#44; 84&#37; neutrophils&#44; haemoglobin&#58; 12&#46;1g&#47;dl&#59; platelets&#58; 163&#160;000&#47;&#181;l&#59; urea&#58; 60mg&#47;dl&#44; creatinine&#58; 1&#46;7mg&#47;dl&#59; normal hepatic enzymes&#59; peritoneal leukocytes count&#58; 8800&#47;&#181;l&#44; 96&#37; neutrophils&#46; The Gram staining of the peritoneal fluid revealed single and short-chain bacilli&#46; Empirical intraperitoneal antibiotic treatment was started with vancomycin and ceftazidime&#46; Small&#44; translucent&#44; grey colonies with a discreet beta haemolysis area were found in the peritoneal fluid on blood agar plate cultures following aerobic incubation at 37&#186;C &#40;pH 7&#46;2-7&#46;4&#41;&#44; indicating <span class="elsevierStyleItalic">Listeria monocytogenes</span>&#46; Faecal samples were cultivated&#46; They were negative for <span class="elsevierStyleItalic">Listeria</span>&#44; although it was provided after antibiotic treatment had been started which could have halted its growth&#46; Initial antibiotics were substituted for intravenous ampicillin and intraperitoneal gentamicin&#46; The infection started responding to the antibiotics after 72 hours&#46; Specific antibiotic therapy was maintained for three weeks&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Listeria monocytogenes</span> is the only <span class="elsevierStyleItalic">Listeria</span> among the seven known species that can infect human beings&#46; It is an aerobic gram positive germ &#40;in certain circumstances can also behave like an anaerobic one&#41; which cannot form spores&#46; Despite being present in the environment&#44; it does not usually cause humans to become ill&#46; An incidence of 0&#46;7 cases&#47;100 000 has been calculated&#46;<span class="elsevierStyleSup">13</span> The elderly&#44; newborns&#44; cancer patients&#44; cirrhotic and immunocompromised patients are more susceptible to contracting a <span class="elsevierStyleItalic">Listeria </span>infection&#46; The most common clinical signs include meningitis&#44; endocarditis&#44; gastroenteritis&#44; miscarriage and bacteraemia&#46; Peritonitis caused by <span class="elsevierStyleItalic">Listeria</span> is a rare&#44; dangerous form of the complication&#46; Spontaneous forms of peritonitis caused by <span class="elsevierStyleItalic">Listeria</span> are well known&#44; especially in cirrhosis patients&#46;<span class="elsevierStyleSup">13</span> Around 50 cases have been published and most of them describe Spanish patients&#46;<span class="elsevierStyleSup">14</span> The geographical predilection in Spain is not entirely understood&#44; but may be due to eating habits including the consumption of incorrectly pasteurised dairy products or raw fruit and vegetables&#46;<span class="elsevierStyleSup">14</span></p><p class="elsevierStylePara">For patients undergoing dialysis&#44; peritonitis caused by <span class="elsevierStyleItalic">Listeria</span> is very rare&#46; Table 1 shows the cases published to date in the medical literature&#46; All cases have occurred in immunocompromised patients&#44; due to illness or medication&#46;</p><p class="elsevierStylePara">It has been reported that natural killer cells &#40;non-antigen first line of defence&#41; in heart failure patients are in a situation of anergy and respond less to the molecules that usually stimulate them&#44; such as interleukin-2 and interferon-gamma&#46; These patients are therefore considered to be at greater risk of developing infections given their immunocompromised sitution&#46;<span class="elsevierStyleSup">15</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Listeria</span> is one of the most virulent pathogens which cause food borne diseases&#46; It has a mortality rate of 20&#37;-30&#37;&#44; higher than almost all other food borne illnesses&#46; It was difficult to find the source of infection in our patient&#44; but given that he lives in a rural area it is possible that he ingested incorrectly pasteurised dairy products&#44; which would have caused this germ to colonise the intestine&#46; The bacteria would have then invaded the mucosa&#44; reaching the peritoneum&#46; Unfortunately&#44; this has not been confirmed&#44; given that the faecal culture sample was provided after antibiotic treatment had been started&#46; However&#44; the hypothesis mentioned above seems the most plausible&#46;<span class="elsevierStyleSup">12</span> Furthermore&#44; chronic heart failure could have been involved in this process&#46; In this situation&#44; the patient would have intestinal oedema&#44; increased permeability and would be more susceptible to bacterial invasion&#46;<span class="elsevierStyleSup">16</span></p><p class="elsevierStylePara">The antibiotic treatment of choice for <span class="elsevierStyleItalic">Listeria</span> infection is penicillin or ampicillin&#44; which can be administered in combination with aminoglycosides or not&#46;<span class="elsevierStyleSup">12</span> However&#44; there is no clear indications as to which treatment is better for peritonitis caused by <span class="elsevierStyleItalic">Listeria</span>&#44; or how long treatment should last&#46; Vancomycin may not be effective since <span class="elsevierStyleItalic">Listeria</span> is an intracellular microorganism&#46;<span class="elsevierStyleSup">5&#44;6&#44;9</span> Both trimethoprim-sulfamethoxazole and erythromycin have been used successfully for patients allergic to penicillin&#46;<span class="elsevierStyleSup">2&#44;12</span> For most cases&#44; peritonitis responds rapidly and effectively to antibiotics&#44; without needing to withdraw the peritoneal catheter&#46;</p><p class="elsevierStylePara">In summary&#44; we must remember that <span class="elsevierStyleItalic">Listeria monocytogenes</span> is a germ that can cause peritonitis in patients undergoing peritoneal dialysis&#44; where rod-shaped gram positive bacteria can be found&#44; even in patients considered immunocompetent&#46; Above all&#44; prevention is the best weapon to combat this zoonosis&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10631&#95;108&#95;17667&#95;en&#95;t110631&#46;jpg" class="elsevierStyleCrossRefs"><img src="10631_108_17667_en_t110631.jpg" alt="Characteristics of 11 cases of peritonitis caused by Listeria monocytogenes in patients undergoing peritoneal dialysis"></img></a></p><p class="elsevierStylePara">Table 1&#46; Characteristics of 11 cases of peritonitis caused by Listeria monocytogenes in patients undergoing peritoneal dialysis</p>"
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