This article is more than 5 years old. Information may no longer be current.
A 10-year-old girl with flu-like symptoms
Click Here to Manage Email Alerts
A 10-year-old Hispanic girl presented to our clinic with a 1-day history of fever up to 99.9·F and “flu-like” symptoms.
On further questioning, she complained of a runny nose, headaches, body chills and pain on urination.
She denied vomiting or diarrhea. Her past history was significant for a diagnosis of microscopic polyangiitis diagnosed at 6 years of age that resulted subsequently in renal failure. The patient was getting daily peritoneal dialysis and awaiting a renal transplant. She was not currently taking any immunosuppressive agents and her mother stated that she urinates in addition to the daily dialysis and her most recent dialysate fluid was clear.
On physical examination, the patient had a temperature of 99.1·F, heart rate of 114 beats/minute, respiratory rate of 28/minute and blood pressure of 130/86. She appeared comfortable and in no distress. Examination was within normal limits, except for pronounced tenderness in the left lower quadrant and suprapubic area. Bowel sounds were normal.
A urine dipstick showed trace leukocytes, 2+ protein and 3+ blood.
What’s your diagnosis?
- Urinary tract infection
- Peritonitis
- Influenza
- Strep pharyngitis
Diagnosis
The patient was diagnosed with peritonitis (b). She was seen at the emergency room, where peritoneal fluid was collected for studies and was noted to be cloudy, and was admitted for further management.
Microscopic polyangiitis was initially considered a 'microscopic' form of polyarteritis nodosa and was not definitively distinguished from it until the Chapel Hill nomenclature (1994). Microscopic polyangiitis is a systemic necrotizing vasculitis of small vessels. Its typical clinical manifestations are rapidly progressive glomerulonephritis and alveolar hemorrhage. Other possible symptoms resemble those encountered in polyarteritis nodosa. Microscopic polyangiitis belongs to the group of ANCA-associated vasculitides.
End stage renal disease (ESRD) is one possible outcome of microscopic polyangiitis. Chronic peritoneal dialysis (CPD) remains the most common dialysis modality utilized for the management of children with ESRD. Peritonitis remains a frequent complication of peritoneal dialysis in children and is the most common reason for technique failure. Risk factors for infection include young age, the absence of prophylactic antibiotics at catheter placement, spiking of dialysis bags, and the presence of a catheter exit-site or tunnel infection. Despite the decreasing incidence of CPD-related infectious complications in both children and adults in the past 2 decades, peritonitis remains the most significant complication of CPD in the pediatric population.
Peritoneal dialysis patients presenting with abdominal pain and/or cloudy effluent should be presumed to have peritonitis and evaluated for this infection. While a small percentage of pediatric and adult patients with peritonitis may present with clear effluent and abdominal pain, the presence of a cloudy peritoneal effluent almost always indicates infectious peritonitis. The severity of the presentation of abdominal pain and fever in patients with peritonitis varies and is somewhat organism-specific; for example, the severity is generally mild-moderate with culture negative peritonitis and peritonitis secondary to coagulase-negative Staphylococcus aureus, whereas it is of greater severity with peritonitis resulting from Streptococcus, gram-negative organisms, S. aureus and fungi.
To prevent a delay in treatment, antibiotic therapy should be initiated as soon as the diagnosis of peritonitis is suspected and after samples of the dialysis effluent are obtained for Gram’s stain, cell count and culture. If signs of severe infection, such as pain and fever are present, it is often advisable not to wait for confirmation of the cell count from the laboratory. Antibiotics selected for the treatment of peritonitis should be administered intraperitoneally to ensure immediate bioavailability.
The mortality rate in children who develop acute peritonitis is approximately 1%. Peritonitis remains the most significant complication of peritoneal dialysis in children.
Physicians should always err on the side of caution even when the history is not always clear cut.
Sabiha Hussain, MD, is a pediatrician in Bakersfield, Calif.
For more information:
- Chadha V. Pediatr Nephrol. 2010;25:425-440.
- Pagnoux C. Presse Med. 2010;36: 895-901.