A rare case of hematologic peritonitis complicating secondary myelofibrosis
DOI:
https://doi.org/10.25796/bdd.v8i3.87085Keywords:
peritoneal dialysis, peritonitis, cloudy peritoneal dialysate, culture-negative peritonitis, secondary myelofibrosisAbstract
Peritonitis is a frequent complication of peritoneal dialysis. Its diagnosis is based on clinical signs (pain, cloudy effluent), intraperitoneal hyperleukocytosis (> 0.1×109/L with more than 50% polynuclears), or a positive culture. Although the majority of peritonitis cases are of infectious origin, there are also cases due to non infectious origin, which can lead to the inappropriate use of antibiotics and delayed diagnosis. We report the case of a 78-year-old male patient with a complex haemopathy that combined paroxysmal nocturnal haemoglobinuria, despite treatment with ravulizumab, and essential thrombocythemia, which transformed into myelofibrosis. After the initiation of peritoneal dialysis treatment, he presented with occasionally cloudy dialysis fluid rich in leukocytes (up to 0.442 ×10^9/L), with no evidence of infection (negative cultures and DNA16S PCR, moderate CRP, and an absence of atypical cells). The origin of the intraperitoneal hyperleukocytosis was attributed to myelofibrosis-related blood hyperleukocytosis. The clinical course was unfavorable, leading to palliative management.
This case illustrates the difficulty of managing this complication in peritoneal dialysis patients. Although infectious peritonitis is the most common first-line diagnosis, it is important to consider various differential diagnoses in cases of culture-negative peritonitis, particularly hematological causes (leukemia, lymphoma, myelofibrosis). However, forms with a predominance of neutrophils in the dialysate may simulate an infection. The absence of fever, elevated CRP, and a correlation between blood and peritoneal hyperleukocytosis should help in making a differential diagnosis. Immunophenotyping or molecular biology in the dialysate could refine the diagnosis. This case highlights a possible cause of sterile peritonitis due to myelofibrosis with hyperleukocytosis, and calls for recommendations to be adapted to increasingly complex clinical situations.
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