腹膜透析相关嗜酸粒细胞性腹膜炎1例报道并文献复习

Peritoneal dialysis-related eosinophilic peritonitis: a case report and literature review

腹膜透析相关性腹膜炎是腹膜透析（peritoneal dialysis）重要且常见的并发症。嗜酸粒细胞性腹膜炎（eosinophilic peritonitis）是一种少见的特殊类型的非感染性腹膜透析相关性腹膜炎,目前病因未明,通常与患者对透析系统的组成成分（如管路或透析液）过敏,或与细菌、真菌、结核等感染相关,临床表现为无症状性腹膜透析液（简称腹透液）混浊、低热、轻度腹痛、腹透液中嗜酸性粒细胞比例增高,多具有自限性。腹膜透析相关嗜酸粒细胞性腹膜炎在1967年由Lee等[1]首次报道。近年来随着腹膜透析技术的推广及发展.

Peritoneal dialysis（PD）-related peritonitis is recognized as a common complication of peritoneal dialysis. Eosinophilic peritonitis is a rare type of non-infection PD-related peritonitis. Eosinophilic peritonitis in continuous ambulatory peritoneal dialysis（CAPD） patients was first reported in 1967. The cause of eosinophilic peritonitis is obscure,however it may be related to some etiologies：（1） hypersensitivity to PD materials,including catheter or dialysate;（2） bacteria,fungal or mycobacterium tuberculosis infection. Clinical investigations include asymptomatic cloudy PD effluent,fever,abdominal pain and eosinophil count elevate in PD effluent. Eosinophilic peritonitis is usually mild and self-limited. With the development of PD,more eosinophilic peritonitis cases and researches were reported. Here,we report a patient on CAPD with eosinophilic peritonitis. A 71-year-old female patient developed end-stage renal disease for 4 years and underwent CAPD（2 000 m L of 1. 5% dialysis solution with four exchanges daily）for 5 months. With a history of unclean food,she was hospitalized for complaints of diarrhea,fever and cloudy peritoneal effluent for 10 days. Dialysis effluent showed an elevated white blood cell（WBC）count of 1 980 cell/mm3,with 60% polymorphonuclear cells. She was diagnosed as PD-related peritonitis,and therapy was initiated with intraperitoneal ceftazidime 1 g once a day and vancomycin 500 mg every other day. She was admitted to the hospital as the symptoms were not relieved. Her peripheral blood cell count showed a total WBC count of 6 940 cells/mm3,36. 8% eosinophil. Her PD effluent analysis showed turbidity,total WBC count of 1 480 cells/mm3,and 83% polymorphonuclear cells. Her dialysate bacteria culture,fungus culture,polymerase chain reaction for Mycobacterium tuberculosis（TBPCR）,acid-fast stain were all negative. On admission day 4,the treatments were changed to levofloxacin200 mg once a day and vancomycin 500 mg every other day. After two weeks of antibiotics treatment,patient＇s symptoms were not completely improved and her dialysis effluent remained cloudy. Her blood eosinophil count elevated to 36. 8%,eosinophil proportion in PD effluent 90% and PD effluent pathological findings showed eosinophil 90%. Eosinophilic peritonitis was diagnosed and a decision was made to give loratadine daily dose of 10 mg orally. The possible reasons might be the patient＇s allergy to some components of PD solution or connection systems in the beginning of PD,and this bacterial peritonitis episode,as well as the application of vancomycin,might lead to the fact that eosinophilic peritonitis acutely developed. For there was no improvement in clinical symptoms,loratadine was stopped,and the patient was discharged 18 days later,and received follow-up closely. Two months later,eosinophil count in blood and PD fluid decreased to normal range with no symptom. This case reminds us that in any PDrelated peritonitis patient with prolonged symptoms after appropriate antibiotic therapy,and typical clinical symptoms,the diagnosis of eosinophilic peritonitis should be considered. For the count and percentage of eosinophils are not routinely reported in most laboratories,doctors need to contact the department of laboratory and the department of pathology,to confirm the cell count and proportion of eosinophils in dialysis effluent,so as to make the definite diagnosis,which can not only avoid antibiotics overuse,but also avoid antibiotics-induced eosinophilic peritonitis（such as vancomycin）.