Iselin, H.

Nadal, D.

Neuhaus, T. J.

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Nephrol Dial Transplant (1996) 11: 199-200Case ReportNephrologyDialysisTransplantationHaemophilus influenzae: a cause of peritonitis in peritoneal dialysisT. J. Neuhaus1, H. Iselin1 and D. Nadal2'Division of Nephrology and 2Unit of Infectious Diseases, University Children's Hospital, Zurich, SwitzerlandKey words: child; Haemophilus influenzae; peritonealdialysis; peritonitisIntroductionPeritonitis, a major complication of peritoneal dialysis(PD), is usually caused by coagulase-negative staphylo-cocci, Staphylococcus aureus and streptococci [1,2].Although infections with Haemophilus influenzae arecommon in children, peritonitis due to this pathogenis rare [3-5]. We report the first child on PD with aperitonitis due to H. influenzae, a fastidious organismrequiring adequate culture media for growth.Case reportHie patient was a 27-month-old child with theDenys-Drash syndrome (triad of Wilms' tumour,diffuse mesangial sclerosis, and male pseudohermaph-roditism) [6]. At birth the phenotype was unequivoc-ally female; thus the child was raised as a girl. At theage of 16 months she presented with a right-sidedWilms' tumour stage I and proteinuria. Unilateralnephrectomy was performed, followed by chemother-apy for 4 months. Extratumorous renal tissue showeddiffuse mesangial sclerosis. Chromosome analysisrevealed a male karyotype 46,XY and a constitutionalmutation in the WT1 locus. Ultrasound and computingtomography showed an infantile uterus; however, thegonads could not be classified, even at laparotomy.End-stage renal failure occurred at the age of 21months. The second kidney was removed, and auto-mated continuous cycling peritoneal dialysis (CCPD)during the night (PAC-Xtra cycler, Baxter) wascommenced. After 1 month the child developed a tunnelinfection, without concomitant peritonitis, due toPseudomonas aeruginosa, which was successfully treatedwith a 10-day course of intraperitoneal ceftazidime.At the age of 24 months the child presented afebrilewith cloudy dialysate and slight abdominal pain. ThereCorrespondence and offprint requests to: T. J. Neuhaus, Division ofNephrology, University Children's Hospital, Steinwiesstr. 75,CH-8032 Zurich, Switzerland.was neither a tunnel nor an exit-site infection.Microscopy of the dialysate showed 6700 x 106/l whitecells. Gram staining was negative. After taking samplesof dialysate and blood, intraperitoneal gentamicin andcefazolin were administered. Within 48 h, the dialysatebecame clear and the white cell count normalized(5-15xlO6/l).For bacterial cultures, sediment from 50 ml high-speed centrifuged dialysate was plated onto sheep bloodand MacConkey agar plates. In addition uncentrifugeddialysate was instilled into four haemoculture bottles(10 ml each; Bactec Plus, Becton Dickinson, Basel,Switzerland), which were immediately enriched withhemin (X factor) and nicotinamide adenine dinucleotide(NAD, V factor) (Bactec®-FOS™, Becton Dickinson).Dialysate cultures in these bottles grew non-groupableH. influenzae biotype 2, sensitive to both administeredantimicrobials. In contrast, the agar plates remainedsterile. Haemocultures and a nasal swab (also culturedon chocolate agar) showed no growth. Gentamicin wasdiscontinued and the patient was treated for 10 dayswith cefazolin, and has been well since.DiscussionHaemophilus influenzae is an important pathogen inchildren. Peritonitis due to this organism has rarelybeen found in previously healthy [3,4] and in nephxoticchildren [5]. PD peritonitis due to H. influenzae hasnot been described in children, in contrast to occasionalreports from adults [7-10]. The source of infection inour patient is unclear. Tunnel, exit-site, and surround-ing skin of the Tenckhoff catheter were unremarkableand there were no signs of upper respiratory tractinfection. Peritonitis rate in children on PD is higherthan in adults [2]. Since 1979 we have treated 27children with end-stage renal failure with ambulatoryPD. The rate of peritonitis has declined with improvingtechniques to one episode per 20 months since 1989.Cultures of peritoneal fluids from patients with PDperitonitis (defined as > 100 x 106/l white cells) havebeen reported as negative in up to 50% of all episodes[1,2]. Relevant reasons include low concentrations ofmicro-organisms, intracellular survival of and surfacetension between bacteria, and presence of antibiotics[1]. Another reason may be the lack of specific growthO 1996 European Dialysis and Transplant Association-European Renal Association200 T. J. Neuhaus et al.factors in the culture media. Haemophilus spp. arenutritionally fastidious and require either exogenoushemin (X factor) or NAD (V factor) or both.Chocolate agar but not conventional sheep blood agarcontains X and V factor in sufficient amounts. Whereasboth factors are provided in haemocultures from thepatient's blood, they need to be added to the mediawhen culturing dialysate. Thus the use of chocolateagar should routinely be introduced for cultures ofdialysate. Direct instillation of (even uncentrifuged)dialysate into haemoculture bottles containing X andV factor-enriched medium, as done in the present case,may optimize detection of Haemophilus spp.We conclude that (1) Haemophilus spp. peritonitisdoes occur in children, and (2) may be missed ifbacterial cultures of dialysate are not done withadequate media for the growth of these pathogens.References1. v Graevenitz A, Amsterdam D. Microbiological aspects ofperitonitis associated with continuous ambulatory peritonealdialysis. Clin Microbiol Rev 1992; 5: 35-482. Avner ED, Chavers B, Sullivan EK, Tejani A. Renal trans-plantation and chronic dialysis in children and adolescents:the 1993 Annual Report of the North American PediatricRenal Transplant Cooperative Study. Pediatr Nephrol 1995;9: 61-733. Chang MJ, Controni G. Primary peritonitis due to Haemophilusinfluentae type b in a previously healthy child. J Clin Microbiol1983; 18: 725-7264. Gorski J, Ingall D, Yogev R. Primary peritonitis associated withHemophilia influenzae bacteremia in a normal child. Clin Pediatr1983; 22: 1835. Rubin HM, Blau EB, Michaels RH. Hemophilus and pneumoc-cocal peritonitis in children with the nephrotic syndrome.Pediatrics 1975; 56: 598-6016. Coppes MJ, Huff V, Pelletier J. Denys-Drash syndrome: relatinga clinical disorder to genetic alterations in the tumor suppressorgene WT1. J Pediatr 1993; 123: 673-6787. Gokal R, Francis DMA, Goodship THJ et al. Peritonitis incontinuous ambulatory peritoneal dialysis. Lancet 1982; 2:1388-13918. Spencer RC. Infections in CAPD. J Med Microbiol 1988; 27:1-99. Ferrari R, Dasgupta MK. A case of CAPD peritonitis due toHemophilus influenzae. Peril Dial Int 1993; 13: 323-32410. Maxwell PH, Abbott J, Koffman CG, Dave J. Haemophilusinfluenzae as a rare cause of CAPD peritonitis. J Infect 1993;26: 340-34Received for publication: 29.8 95Accepted- 6.9.95

Haemophilus influenzae: a cause of peritonitis in peritoneal dialysis

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