The 36 year- old male patient, after receiving CAPD treatment for 4 months, consulted our clinic because of stomachache, diarrhea, nausea, vomiting and continous fever. The patient had been diagnosed with chronic renal deficiency and had been followed up with diagnosis of predialysis CRF for 4 years. The patient was referred to us because of his symptoms such as of nausea, vomiting, weakness, and a general condition of fatigue. Immediate care involved an urgent hemodialysis followed by CAPD and planning for renal replacement therapy.
Through a physical examination, the patient's blood pressure was 110/70 mmHg. The general condition was bad and pulmonary sounds in the respiratory system were diminished slightly in lower zones. On CAPD catheter's entering segment, infections were not seen.
In a laboratory investigation Hg was at 9.1gr/dl, Htc was at %27.6, WBC was at 5200/mm3, the platelet count was at 203000/mm3, and the erythrocyte sedimentation rate was at 22 mm/h. In biochemical findings, furthermore, serum creatinine was at 6.05 mgr/dl [ref. 0,5-1,4], urea nitrogen was at 38 mgr/dl [ref.5-20], protein was at 3.8gr/dl [ref:6-8.5], albumin was at 1.2 gr/dl [ref:3,5-5], and lactic dehidrogenase was at 565 iu/L. Serum sodium, potassium, glucose, bilirubin, alkaline phosphatase, aspartate and alanine aminotransferase, gamma-glutamyl transpeptidase, amylase, triglyseride, and cholesterol were normal. A coagulation factor protrombin time was found to be 18.7 sn. C-reactive protein was 9.54 mgr/dl. Bilateral costofrenic angles were blunted in posteroanterior pulmonary graphy.
No parasites and cystes were found in fecal examination due to diarrhea. No pathogenic agent was detected in stool cultures. In peritoneal cell counting, 1600/mm3 cell were detected and it was seen that 70 percent of these cells were polymorphonuclear leukocytosis (PMNL). The patient was given ceftazidime (IV), cephazol, and amikacin (intraperitoneal), but no benefit was noticed after 12 days of antibiotherapy and there was no growth in peritoneal fluid cultures. There were PMNL present but no microorganism could be detected. Acid-fast basilli (AFB) was found to be positive in the gram staining of peritoneal fluid in the remaining follow up periods, and the patient had begun antituberculosis therapy in fours(with isoniazid, rifampin, ethambutol and pyrazinamide). Tuberculin skin test was anergical. On the 15th day of anti tbc therapy, peritoneal fluid cell count decreased to 300/mm3 . Peritoneal fluid bacterial culture, blood cultures, throat culture and urine culture were negative but peritoneal fluid tbc culture was found to be positive, in Lowenstein- Jensen medium in 24 days. The patient was followed up with the treatment for recovery with an anti-tbc treatment.
The peritoneal fluid of the patient was sent to be examined with Gram staining and Ziehl Neelsen staining. The peritoneal fluid was centrifuged at 3,000 x g for 15 minutes and the sediment was stained by Gram and Ziehl-Neelsen staining. The Gram staining showed PMNL presence but no microorganisms. The Ziehl-Neelsen staining(AFB) was positive.
The peritoneal fluid was transferred to 10 ml sterile glass tube and centrifuged at 3,000 x g for 15 minutes. The concentrated sediment was inoculated onto Lowenstein Jensen (LJ) medium without prior decontamination. LJ medium was incubated at 37 C. Two specimens were later sent to be examined with Ziehl Neelsen staining on two different days. Both of them were detected to be positive for Ziehl Neelsen staining.
LJ medium was examined for growth twice weekly for the first two weeks and once a week thereafter until the eighth week. After 24 days, the colonies were able to be seen on LJ medium. Positive growth was confirmed by Ziehl Neelsen staining.