Unexpected rate of severe leucopenia with the association of mycophenolate mofetil and valganciclovir in kidney transplant recipients.

Here, we report on a patient with a gram-negative CAPDrelated peritonitis presumably caused by an ascending infection due to fallopian tube capture of the CAPD catheter. An 81-year-old woman with coronary heart disease and end-stage renal disease as a consequence of diabetes mellitus underwent an uncomplicated surgical insertion of a Tenckhoff catheter. After 2 weeks, CAPD was started without difficulty. Another 2 weeks later she experienced an acute pain in the middle of the abdomen. The effluents became cloudy and haemorrhagic, and she was admitted to our dialysis centre. On physical examination we saw a non-acutely ill-looking woman with a slightly diffuse tender abdomen. There were no signs of an exit-site infection. Abdominal radiographs showed the catheter positioned in the minor pelvis. The CAPD fluid had an elevated white cell count (WCC) of 4.1 10/l. The gram stain was negative and the fluid was inoculated into a blood culture system. (Bactec , BD diagnostics, NJ, USA). The peripheral WCC was 6.6 10/l and serum C-reactive protein (CRP) was 192mg/dl (normal <6mg/dl). Intraperitoneal ceftriaxone (2 g/day) was administered, and CAPD was continued. Symptoms rapidly resolved and on day 3, the CRP had declined to 98mg/dl and leucocyte count in the CAPD fluid to 0.4 10/l. In the first CAPD fluid, cultured on admission, an Escherichia coli sensitive to ceftriaxone was identified. On day 5, the patient died unexpectedly of sudden cardiac death. The post-mortem examination of the peritoneal cavity showed a partial adhesion of the left fallopian tube to the CAPD catheter. The fimbriae were partially haemorrhagic and penetrated the catheter lumen. Histology demonstrated chronic inflammation of the fimbriae. Furthermore, no diverticulitis or organ perforations were seen. To our best knowledge, this is the first case indicating that entrapment of a CAPD catheter into the fallopian tube and fimbriae is a cause of CAPD-related peritonitis. Fallopian tube wrapping is a rare cause of catheter obstruction [3,4]. However our patient did not encounter inor out-flow problems, probably because of residual well-functioning drainage holes. CAPD peritonitis may occur by several routes. The connection sites, tunnel and exit-site are thought to be the most frequent infection routes [2]. The transluminal route, such as migration across the bowel wall, and the haematogenous route are less frequent. The ascending route via the genitourinary tract seems most likely in this case. This case demonstrates that although extremely rare, entrapment of a CAPD catheter into a fallopian tube and fimbriae is a possible cause of CAPD-related peritonitis. This underlines the different routes of infection in CAPDrelated peritonitis.