A 54-year-old woman was admitted to the hospital in May 1992 with a chief complaint of diffuse abdominal pain for a duration of one week. She had been treated with CAPD since January 1992 for end-stage renal disease of unknown etiology. One week before admission, the patient developed diffuse abdominal pain, fever and chill and she was treated with intraperitoneal cefazolin and tobramycin for six days at the out-patient department. At that time, the peritoneal fluid contained 2,250 leukocytes per mm3 with 85% polymorphonuclear cells, and routine culture yielded no organisms. In spite of six days' antibiotics therapy, there was no improvement.
The temperature was 37.8 C, the pulse rate was 87 per minute and the respirations were 25 per minute. The blood pressure was 140/90 mmHg. On physical examination, the patient was alert and appeared acutely ill. Examination of the head and neck was normal, except for pale conjunctiva. The heart and lungs were normal. The abdomen was rigid and diffusely tender but the catheter exit site showed no signs of infection or leakage; the liver and spleen were not palpable. There was peripheral edema. The peripheral leukocyte count was 9,000/mm3, with 88% neutrophils, 8% lymphocytes, 4% monocytes and hemoglobin was 7.5 g%. Her serum sodium was 137 mEq/L, potassium 4.2 mEq/L, chloride 106 mEq/L, calcium 8.3 mEq/L, phosphate 2.7 mEq/L, urea nitrogen 27 mg/dl and creatinine 6.2 mg/dl. Serum total protein was 6.0 g/dl, albumin 2.9 g/dl, total bilirubin 0.3 mg/dl, aspartate aminotransferase 17 IU/L, alanine aminotransferase 3 IU/L and alkaline phosphatase 39 IU/L. X-ray films of the chest and abdomen were normal.
The peritoneal fluid was cloudy and contained 1,000 leukocytes per mm3, with 90% polymorphonuclear cells. Intraperitoneal ceftizoxime and amikacin were administered after routine culturing of the peritoneal fluid was done. Initial gram and acid-fast staining revealed no organisms and routine cultures showed no growth. Abdominal pain was persistent and routine cultures again showed no growth, but follow-up acid-fast staining was reported to be positive. Therefore, cultures for mycobacteria were requested repeatedly. Antibiotics were discontinued and antituberculous drugs (isoniazid, rifampin, ethambutol and streptomycin) were begun. The peritoneal catheter was surgically removed and hemodialysis was begun.
Atypical mycobacteria, not Mycobacterium fortuitum, grew three times after 2 weeks of incubation periods. Colonies of atypical mycobacteria were sent to Korean Institute of Tuberculosis, Korean National Tuberculosis Association for identification and susceptibility tests, and they were identified as M. fortuitum. The results of the identification test are given in Table 1. The result of susceptibility test against antituberculous drugs showed "all resistance". Test against antimicrobial agents was not performed. Empiric therapy with intravenous use of ceftizoxime and amikacin was started and the patient improved. Until now, she has done well on hemodialysis.