A Case of Fulminant Sclerosing Peritonitis Presented Like Acute Culture-Negative Peritonitis and Successfully Treated with Corticosteroid Therapy
A 28-yr-old man had been maintained on continuous ambulatory peritoneal dialysis (CAPD) for 6 yr due to end-stage renal disease of unknown etiology. He used Baxter CAPD system and dialysate with lactate as the base. In December 2011, he had first episode of uncomplicated peritonitis by methicillin-sensitive Staphylococcus epidermidis, which was treated with intraperitoneal cefazolin. On April 06, 2012, he was admitted due to diffuse abdominal pain which had developed 5 days before admission. At the time of admission, blood pressure was 143/77 mmHg, body temperature 36.4℃, height 155 cm, and weight 39 kg. Physical examination showed decreased bowel sound and diffuse abdominal tenderness without rebound tenderness. Laboratory tests showed the following: hemoglobin 12.4 g/dL, hematocrit 35.6%, leukocyte count 8,540/µL with neutrophil 86.4%, platelet 219,000/µL, C-reactive protein (CRP) 5.17 mg/dL, blood urea nitrogen 74.5 mg/dL, serum creatinine 16.59 mg/dL, glucose 184 mg/dL, cholesterol 181 mg/dL, total protein 8.2 g/dL, albumin 4.0 g/dL, AST 19 U/L, ALT 23 U/L, total bilirubin 0.42 mg/dL, alkaline phosphatase 258 IU/L, CK 96 U/L, LDH 411 U/L, amylase 7 U/L, lipase 42 U/L, and peritosol leukocyte count 66/µL with neutrophil 75%. On the fifth hospital day, CRP remained high (6.05 mg/dL) and peritosol leukocyte count was 297/µL with neutrophil 90%. Repeat cultures were all negative for bacteria, fungi, and mycobacteria. Despite numerous antimicrobial agents, diffuse abdominal pain persisted and peritosol leukocyte count remained high (594/µL with neutrophil 57%). On the eleventh hospital day, PD catheter was removed, and he was switched to hemodialysis. Nevertheless, his condition deteriorated. On the twenty-first hospital day, computed tomography (CT) scan of the abdomen () showed diffuse thickening of parietal peritoneum and moderate amount of ascites. On the twenty-third hospital day, oral prednisolone was prescribed at a dose of 40 mg/day (1.0 mg/kg/day) on the diagnosis of fulminant SP. On the next day after corticosteroid therapy, he was getting better with decreased abdominal pain. On the twenty-fifth hospital day, he did not have abdominal pain. CRP decreased significantly from 19.49 mg/dL to 6.75 mg/dL (). On the thirty-ninth hospital day, he was discharged with normalization of CRP (0.22 mg/dL). On June 20, 2012, a follow-up CT scan () showed decreased amount of ascites without significant change of peritoneal thickening. In August 2012, he is still free of abdominal pain with a dose of 10 mg/day of oral prednisolone.