Bacillus Cereus Peritonitis in a Chronic Peritoneal Dialysis Patient
Bacillus Cereus Peritonitis in a Chronic Peritoneal Dialysis Patient
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慢性腹膜透析患者的蜡样芽胞杆菌腹膜炎
DOI：
10.1177/089686089701700517
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发表时间：
1997
影响因子：
2.8
通讯作者：
T. Chugh
中科院分区：
文献类型：
--
作者：
N. Ai;M. Nampoory;K. Johny;T. Chugh
编辑：腹膜炎仍然是维持性腹膜透析（PD）治疗终末期肾衰竭（ESRF）患者的主要问题。我们病例中遇到的常见微生物是革兰氏阳性菌，在间歇性腹膜透析（IPD）和CAPD腹膜炎发作中分别占52.8%和60.5%（1）。我们报告一个非常罕见的情况下，蜡状芽孢杆菌腹膜炎的病人对IPD。1例65岁男性糖尿病肾病ESRF患者过去2年一直接受IPD治疗。在此期间，他未发生任何腹膜炎事件。1995年5月21日，他出现持续一天的腹痛和恶心。他呕吐了一次，两次水样腹泻。这些症状发生在他正常午餐后几个小时。体格检查的阳性结果包括体温37.6 ℃、弥漫性腹部压痛和反跳。检查时透析液浑浊。冲洗的透析液显示白细胞计数为0.2 x 109/L。腹膜液存款的革兰氏染色涂片显示许多脓细胞和革兰氏阳性、长而粗的杆菌，其中心和旁中心有孢子。生物体在细胞内和细胞外形成。孢子没有使杆菌的身体隆起。将液体在血液、麦康凯和巧克力琼脂上培养，在37°C下进行有氧和厌氧培养过夜。有一个纯粹的大量生长的大，提出了菌落与波状边缘和β溶血。细菌学鉴定为B。蜡状。根据经验，患者开始接受万古霉素（静脉注射1 g）和庆大霉素（静脉注射80 mg作为负荷剂量，随后腹腔注射8 mg/L庆大霉素）。在敏感性研究中，该微生物对万古霉素、替考拉宁、克林霉素和红霉素敏感，但对哌拉西林和头孢菌素耐药。患者术后改善，腹膜液异常在24小时内消退。患者出院回家，完成万古霉素疗程，每周1 g，持续4周。随访培养结果为阴性，患者在IPD中保持良好。蜡状芽孢杆菌已从多种食品中分离出来。它可能作为一种致病物种，并在食用煮熟的米饭，干燥的食物和乳制品后引起食物中毒，它在其中生长并形成肠毒素（2）。此外，它可能是肾脏疾病患者和免疫抑制患者的致病菌。在中东地区，大量食用煮熟的米饭非常流行，这种饮食习惯可能导致芽孢杆菌感染的发生。万古霉素和庆大霉素的初始抗生素治疗在该患者中是成功的，因为该微生物对前一种药物敏感，这一经验进一步支持了我们使用这两种药物进行初始经验性治疗的实践。蜡样芽孢杆菌感染并发维持性腹膜透析是非常罕见的。之前曾报告过一例IPD（3）和2例CAPD（4，5）。我们建议医生警惕以胃肠道症状为主的腹膜透析患者发生不寻常细菌性腹膜炎的可能性。
Editar: Peritonitis continues to be a major problem with maintenance peritoneal dialysis (PD) in the management of patients with end-stage renal failure (ESRF). The common organisms encountered in our cases are gram-positive bacteria in 52.8% and 60.5% for intermittent peritoneal dialysis (IPD) and CAPD peritonitis episodes, respectively (1). We report a very rare instance of Bacillus cereus peritonitis in a patient on IPD. A 65-year-old male patient with ESRF due to diabetic nephropathy had been on IPD for the previous 2 years. He had not experienced any episodes of peritonitis during this period. On 21 May 1995 he presented with one-day duration of abdominal pain and nausea. He vomited once and had two attacks of watery diarrhea. These symptoms occurred a few hours after his regular lunch. Positive findings on physical examination included a temperature of 37.6°C, diffuse abdominal tenderness and rebound. Dialysis fluid was cloudy on inspection. Centrifuged dialysate showed 0.2 x 109/L leukocyte count. Gram-stain smear of the deposit of peritoneal fluid showed many pus cells and gram-positive, long, thick bacilli with central and paracentral spores. The organisms were formed both intra and extracellularly. The spores did not bulge the bodies of the bacilli. The fluid was cultured on blood, MacConkey, and chocolate agars, both aerobically and anaerobically at 37°C overnight. There was a pure heavy growth of large, raised colonies with undulate margins and beta hemolysis. Bacteriologically the organisms were identified as B. cereus. The patient was empirically started on vancomycin (1 g intravenously) and gentamicin (80 mg IV as the loading dose, followed by 8 mg/L of gentamicin intraperitoneally). In the sensitivity study, the organism was susceptible to vancomycin, teicoplanin, clindamycin, and erythromycin but resistant to piperacillin and cephalosporins. The patient improved symptomatically, and peritoneal fluid abnormalities resolved in 24 hours. He was discharged home to complete a course of vancomycin, 1 g weekly for 4 weeks. Follow-up cultures were negative and the patient remained well on IPD. Bacillus cereus has been isolated from a large variety of food items. It may act as a pathogenic species and cause food poisoning after consumption of cooked rice, dried foods, and dairy products in which it has grown and enterotoxin has formed (2). Moreover it may act as a pathogenic species in patients with renal diseases and immunosuppressed patients. In Middle Eastern regions, consumption of cooked rice in large amounts is very popular, and such eating habits may contribute to the incidence of Bacillus infection. Initial antibiotic therapy with vancomycin and gentamicin was successful with this patient because the organism was sensitive to the former drug, an experience which further supports our practice of initial empiric therapy with these two drugs. Bacillus cereus infection complicating maintenance PD is extremely rare. One instance has previously been reported for IPD (3) and two for CAPD (4,5). We recommend that the physician be alert for the possibility of unusual bacterial peritonitis in patients on PD who present with predominant gastrointestinal symptoms.