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Recientemente se han descrito casos de peritonitis esclerosante fulminante tras una peritonitis aguda con una respuesta dramática a los esteroides (1-2).Describimos un caso de peritonitis esclerosante fulminante a continuación de una peritonitis fúngica.
To the editor: Cases of fulminant sclerosing peritonitis (SP) following acute peritonitis with a dramatic response to steroids have recently been reported. 1,2 A case of fulminant SP occurring after fungal peritonitis is reported below.
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To the editor: Cases of fulminant sclerosing peritonitis (SP) following acute peritonitis with a dramatic response to steroids have recently been reported. 1,2 A case of fulminant SP occurring after fungal peritonitis is reported below.
A 87-year-old female patient on CAPD had experienced three episodes of peritonitis over the previous 5 years. The last episode was caused by coagulase-negative staphylococci. On the second week of treatment, after an initial good response, the patient experienced severe abdominal pain, with fever and a turbid fluid. Candida albicans grew in peritoneal fluid cultures, and the patient was therefore administered fluconazole and removed the peritoneal catheter, which resulted in immediate clinical improvement. On the fifth day, the patient had severe abdominal pain,
fever of 38 ºC, leukocytosis with increasing neutrophilia, a shift to the left, and a significant increase in Creactive
protein levels (CRP). Repeated blood cultures were negative, and fluconazole-sensitive C. albicans was detected. A CT scan of the abdomen revealed ascites, peritoneal thickening with increased vascularization, and doubtful loop centralization. Steroids (1 mg/kg/day) and tamoxifen (20 mg/day) were started. Abdominal pain and fever disappeared and CRP levels decreased in 48 hours (fig. 1). Steroid treatment was maintained for six months, and the asymptomatic patient continues on tamoxifen with a trend to a decreased dosage (nine months in total).
The most typical presentation of SP is intestinal obstruction. The more insidious form may show ultrafiltration failure
(in HD patients), nausea, vomiting, anorexia, weight loss, and abdominal pain. Initial radiographic findings are
non-specific, and signs of intestinal obstruction later occur. The condition is documented by laparotomy or laparoscopy.
Some case reported of SP starting early after severe peritonitis ran a fulminant course, with a great inflammatory
component and a good response to steroids (fulminant SP).3 Diagnosis is made by exclusion and requires a high grade of suspicion. It could correspond to the pre-encapsulating phase described by Nakamoto, in which steroids may act as an acute treatment for the peritoneal inflammatory phase and association of tamoxifen may probably prevent development of fibrosis. The favorable response of our patient to steroids probably confirms the existence of an inflammatory reaction, and the subsequent clinical and radiographic course may be attributed to the beneficial effects of tamoxifen.
The therapeutic approach proposed by the SP Japanese group would include transfer to hemodialysis, intestinal rest with parenteral nutrition, steroids, and surgery. Coadjuvant tamoxifen treatment has been used in some SP cases
with encouraging results.
In this presentation form, diagnosis of fulminant SP is frequently difficult and based on suspicion. This is why immunosuppressive treatment is often delayed. 1,2 In cases where early immunosuppression had been administered, a more favorable course of the patient has been reported.3
By reporting this case we want to call attention to this acute inflammatory condition occurring after or during the
resolution phase of a severe peritonitis. It should be suspected if an abscess is ruled out. It should be emphasized that early steroid administration clearly improved the course of the condition, and tamoxifen administration was effective as a coadjuvant.
A 87-year-old female patient on CAPD had experienced three episodes of peritonitis over the previous 5 years. The last episode was caused by coagulase-negative staphylococci. On the second week of treatment, after an initial good response, the patient experienced severe abdominal pain, with fever and a turbid fluid. Candida albicans grew in peritoneal fluid cultures, and the patient was therefore administered fluconazole and removed the peritoneal catheter, which resulted in immediate clinical improvement. On the fifth day, the patient had severe abdominal pain,
fever of 38 ºC, leukocytosis with increasing neutrophilia, a shift to the left, and a significant increase in Creactive
protein levels (CRP). Repeated blood cultures were negative, and fluconazole-sensitive C. albicans was detected. A CT scan of the abdomen revealed ascites, peritoneal thickening with increased vascularization, and doubtful loop centralization. Steroids (1 mg/kg/day) and tamoxifen (20 mg/day) were started. Abdominal pain and fever disappeared and CRP levels decreased in 48 hours (fig. 1). Steroid treatment was maintained for six months, and the asymptomatic patient continues on tamoxifen with a trend to a decreased dosage (nine months in total).
The most typical presentation of SP is intestinal obstruction. The more insidious form may show ultrafiltration failure
(in HD patients), nausea, vomiting, anorexia, weight loss, and abdominal pain. Initial radiographic findings are
non-specific, and signs of intestinal obstruction later occur. The condition is documented by laparotomy or laparoscopy.
Some case reported of SP starting early after severe peritonitis ran a fulminant course, with a great inflammatory
component and a good response to steroids (fulminant SP).3 Diagnosis is made by exclusion and requires a high grade of suspicion. It could correspond to the pre-encapsulating phase described by Nakamoto, in which steroids may act as an acute treatment for the peritoneal inflammatory phase and association of tamoxifen may probably prevent development of fibrosis. The favorable response of our patient to steroids probably confirms the existence of an inflammatory reaction, and the subsequent clinical and radiographic course may be attributed to the beneficial effects of tamoxifen.
The therapeutic approach proposed by the SP Japanese group would include transfer to hemodialysis, intestinal rest with parenteral nutrition, steroids, and surgery. Coadjuvant tamoxifen treatment has been used in some SP cases
with encouraging results.
In this presentation form, diagnosis of fulminant SP is frequently difficult and based on suspicion. This is why immunosuppressive treatment is often delayed. 1,2 In cases where early immunosuppression had been administered, a more favorable course of the patient has been reported.3
By reporting this case we want to call attention to this acute inflammatory condition occurring after or during the
resolution phase of a severe peritonitis. It should be suspected if an abscess is ruled out. It should be emphasized that early steroid administration clearly improved the course of the condition, and tamoxifen administration was effective as a coadjuvant.
Bibliography
[1]
1.Rajani R, Smyth J, Koffman CG, Abbs I, Goldsmith DJ.Differential effect of sirolimus vs prednisolona in the treatment of sclrerosing encapsulating peritonitis. Nephrol Dial Transplant 2002:17:2278-2280. [Pubmed]
