A 59-year-old patient on PD since October 2012 with a personal history of type 2 diabetes mellitus and chronic kidney disease secondary to diabetic nephropathy.
She came to the clinic with abdominal pain and cloudy peritoneal fluid, referring to decreased ultrasound.
The patient had been diagnosed two weeks before nasal neoformation.
The peritoneal fluid results were: turbid aspect, 700 leukocytes/μl (mononuclear 80% and polymorphonuclear 20%), despite the predominance of mononuclear cells empirical antibiotic therapy with vancomycin and ceftazidime was initiated.
Abdominal examination showed no signs of peritoneal irritation or masses; the peritoneal catheter exit orifice and the tunnel were normal.
Blood tests showed leukocytes 37000/mm3, platelets 64/mm3, hemoglobin 10.3g/dl, creatinine 5.4mg/dl, urea 180mg/dl, Na 138mEq/dl albumin 4.9mg/dl.
A computerized axial tomography of skull, thorax and abdomen was performed to complete the study of nasal mass in the following days, being informed of disseminated mediastinal and retroperitoneal adenopathies.
The pathology of the nasal biopsy was reported as non-Hodgkin lymphoma of large B cells and the peritoneal fluid cytology showed atypical lymphocytes.
The patient started chemotherapy treatment and received PD with no more dialysis incidents.
The presence of abdominal pain associated with cloudy peritoneal fluid in a PD patient is usually associated with peritonitis.
For the diagnosis of bacterial peritonitis at least two of the three conditions are required: abdominal pain alone or accompanied by other abdominal symptoms, peritoneal fluid with more than 100 leukocytes/μl, more than 50% polymorphonuclear, and culture.
It is difficult to differentiate a peritoneal infection with negative culture from a non-infectious peritoneal inflammation (sterile peritonitis).
A negative peritoneal culture is usually due to technical failures in the processing of samples, so management is complicated, since there is infectious peritonitis without bacterial growth in the culture.
It is advisable to review the culture technique when these are negative in more than 20% of cases and interrogate for the use of antibiotics prior to the patient2.
To achieve rapid diagnosis in cases of sterile peritonitis, the Spanish PD guidelines outline taking into account the presence or absence of cells in the peritoneal fluid and the type of cells.
An increase in polymorphonuclear cells may be due to inflammation of the viscera intraperitoneal or juxtaperitoneal, medications or peritoneal fluid contaminated by endotoxins.
If eosinophils are increased, an allergic reaction to dialysis material, medications, peritoneal irritation due to unpleasant blood or post-traumatic peritonitis due to
The increase in mononuclear cells may be associated with icextrine, mycobacterial infection.
If there are also malformations, ovulation, retrograde menstruation, rupture of an ovarian cyst, hypertonic fluid, peritoneal adhesions, physical exercise and catheter trauma should be considered.
With high mononuclear cells and malignant cells, lymphoma or peritoneal metastases should be considered.
On the other hand, in the absence of cells it may be due to an increase in fibrin or triglycerides3,4.
The literature describes some cases of suspected peritonitis in PD associated with tumor processes, including a patient with recurrent renal cell carcinoma diagnosed in peritoneal fluid cytology5.
Another patient had a sterile peritonitis episode with a history of lymphoma diagnosed ten years earlier.
The peritoneal fluid cytology allowed the observation of atypical lymphocytes and, as in our case, despite peritoneal invasion, continued with the 6MWT technique.
In conclusion, we must point out that in the differential diagnosis of sterile peritonitis we should not forget the possible existence of a neoplasic process.
