Fatih Yılmaz

Ertapenem Associated With Seizures in Treatment of Pyelonephritis in a Chronic Peritoneal Dialysis Patient

angle of this HMD is the same as that of the 16 inch display at the distance of 1 m (diagonal visual angle: 22.4 degrees) and its resolution is 800 × 600 pixels. Although the HMD itself is small, the appearance of the image is almost the same as that of US devices. Moreover, the plane on which HMD displays the images can be adjusted so that the distances to the puncture site and the image on HMD are made the same from the eye. Thereby, we can view the images from US devices with minimal movement of

Outcomes of Renal Transplantation in Patients With Alport Syndrome.

AIM We evaluated the outcomes of patients who underwent renal transplantation (Rtx) due to end-stage renal disease (ESRD) related to Alport syndrome in our study. MATERIALS AND METHODS Twenty-five patients (female/male: 9 [36%]/16 [64%]) who underwent Rtx at our center between 2002 and 2014 were enrolled in the study. Mean ages of patients and donors (cadaveric/living: 8 [32%]/17 [68%]) were 28.2 ± 11.6 and 42.3 ± 15.8 years, respectively. As immunosuppressive therapy, tacrolimus plus mycophenolic acid were used for 17 (68%) patients and cyclosporin plus mycophenolic acid were used for 8 (32%) patients where induction therapy was basiliximab 20 mg (day 0 and 4) for 11 (44%) patients and anti-thymocyte globulin for 8 (32%) patients. Acute rejection was diagnosed using biopsy and evaluated with Banff classification. Analyses were performed by using SPSS 20.0 software with outcomes of mean 75.4 ± 31.4 months follow-up. Patient and graft survival were measured by using Kaplan-Meier survival curve and compared by using log-rank test. RESULTS Graft survival rate was 89%, patient survival rate was 92.9%, and acute rejection rate was 12% (3 cases; 1 was cellular and 2 were antibody-mediated). Delayed graft function was observed in 4 (16%) cases, 1 patient (4%) had BK virus nephropathy and 2 (8%) patients required hemodialysis and had cytomegalovirus infection. At the last follow-up, mean serum creatinine level was 1.57 ± 1.23 mg/dL, spot urine protein creatinine ratio was 0.13 (0.04-1.84), and glomerular filtration rate was 71.7 ± 34.9 mL/min. CONCLUSION Rtx is an effective and successful treatment modality for ESRD cases related to Alport syndrome.

“Streptococcus vestibularis”: A Rare Cause of Peritoneal Dialysis-Related Peritonitis

Dear Editor, Approximately 10–25% of all peritoneal dialysis (PD)-related peritonitis cases are by Streptococcus species, of which the most common is Streptococcus (S.) viridans (1,2). S. vestibularis is a member of the salivarius group of streptococci (Lancefield group F). A 58-year-old female with end stage renal disease secondary to nephrolithiasis who was on automated PD for 41 months, was admitted to our hospital with abdominal pain, vomiting and a cloudy peritoneal effluent in July 2014. During her physical examination, her body temperature was 37.2°C, blood pressure was 135/80 mm Hg and heart rate was 76 bpm. She had poor oropharyngeal/dental health and abdominal tenderness. No signs of infection around the exit site and catheter tunnel were observed. Laboratory tests results are listed in Table 1. She was diagnosed with PD-related peritonitis. Peritoneal effluent and blood cultures for aerobic bacteria, anaerobic bacteria, fungi and mycobacteriae were taken, and 1 g/day/intraperitoneal (IP) and 4 g day/IP ampicillin-sulbactam were empirically initiated. On the second day of treatment, the abdominal pain and cloudy PD effluent resolved. On the third day of treatment, S. vestibularis was identified in the peritoneal effluent culture, which was sensitive for amoxicillin, vancomycin, penicillin G, clindamycin and chloramphenicol. Treatment with combined IP ampicillin-sulbactam and ceftazidime was continued for 14 days and resulted in total cure. Streptococcus vestibularis was described as a new microorganism by Whiley et al. in 1988, and it was first isolated from the vestibular mucosa of the human oral cavity (3). It is a Gram-positive, alpha hemolytic, catalase-negative, non motile, 1 μm diameter facultative anaerobe organism and that grows in chains. It produces urease and hydrogen peroxide. It has been uncommonly associated with human diseases including meningitis, prosthetic and native valve endocarditis, dental infections, bacteremia and septicemia in immunosuppressed organisms (4). S. vestibularis is susceptible to vancomycin and resistant to optochin. In the study by Doyuk et al., treatment was initiated with 2 g day intravenous ceftriaxone and 1 mg/kg tid gentamicin, and was switched to 500 mg bid vancomycin with a good clinical response (4). Infections are likely attributable to hematogenous spread from dental procedures or transluminal contaminationwithoral flora.Considering thepoordental hygiene in our patient, we suggest that our casewas related to contaminationoriginating from theoral cavity. Despite evidence that streptococcal peritonitis cases in general may have a lower mortality rate and less catheter loss than peritonitis cases caused by other Grampositive bacteria, some studies have reported that S. viridans peritonitis may have a higher rate of recurrence and slower response to treatment than peritonitis cases caused by other Streptococcus spp. (1,2). Our patient’s response to treatment was excellent, with no eventual catheter loss and no relapse. Although S. vestibularis is a very rare cause of PDrelated peritonitis, until now, undefined types of Streptococcus spp. might have been the cause of some PD-related peritonitis cases. Some of them may be have been caused by S. vestibularis, however, ours is the first published case on PD-related peritonitis. TABLE 1. Laboratory Tests

Peritoneal Dialysis Related Peritonitis by Sphingomonas Paucimobilis: Letter to the Editor

Dear Editor, Peritonitis remains the most common serious complication associated with peritoneal dialysis (PD). Sphingomonas paucimobilis is a rare cause of PD-related peritonitis. A 63-year-old woman with end-stage renal disease secondary to hypertension on continuous ambulatory peritoneal dialysis (CAPD) for 41 months, was admitted to our clinic with a 1-day history of fever, abdominal pain, vomiting and cloudy peritoneal effluent. She had no history of peritonitis, catheter exit site and tunnel infection. There was no history of immunosuppressive disorder and no usage of immunosuppressive drugs. On examination, body temperature was 37.2 C, blood pressure was 145/80mm Hg and heart rate was 76 bpm. There was diffuse abdominal tenderness with normal bowel sounds; no apparent signs of infection around the exit site and catheter tunnel were observed. Effluent white blood cell count was 4350/mm, with a predominance of neutrophils (54.7%). Abdominal computed tomography and ultrasonography findings were within normal limits. Gram stain examination was negative for bacteria. The patient was hospitalized and peritoneal effluent and blood samples were sent for bacterial, fungal and mycobacterial culture. A diagnosis of PD-related peritonitis was made, and empiric treatment with a once daily 1-g dose of intraperitoneal ceftazidime and a single 1-g starting dose of vancomycin were intraperitoneally administered. On day 3 of treatment, the peritoneal effluent culture (VITEK 2Automated System, Biomerieux Inc., Mercy L’etoile, France) identified S. Paucimobilis, which was sensitive to ceftazidime, cefotaxime, amikacin, and gentamicin but resistant to piperacillin + tazobactam, aztreonam, meropenem, imipenem, and ciprofloxacin. Vancomycin was discontinued and intraperitoneal amikacin (80 mg/day) was added to the treatment regimen. On day 5 of treatment, peritoneal WBC count decreased down to 50 cells/mm, along with complete resolution of abdominal pain and cloudy PD effluent. After 3 weeks of treatment, peritonitis episode was resolved. The peritoneal dialysis catheter was not removed. There are more than 30 species in the genus Sphingomonas spp. The best-known species of the genus is S. paucimobilis. This microorganism was first isolated in a human infection by 1977 and named as Pseudomonas paucimobilis (1). It was reclassified and renamed as S. paucimobilis in 1990 by Yabuuchi et al. (2). S. paucimobilis is strictly aerobic, catalase-positive, oxidase-positive, yellow-pigmented, glucose non-fermenting, Gram-negative bacillus that has a single polar flagellum with slow mobility. This organism is particularly found in natural (water, soil, etc.) and nosocomial environments, including laboratory instruments, respiratory therapy equipment and hospital water systems (hemodialysis fluid, sterile drug solutions and distilled water) (3). Human infections caused by S. paucimobilis are generally rare, and the organism is responsible for two types of infection: sporadic or community-acquired infection and nosocomial infection, particularly in immunocompromised patients (4). S. paucimobilis has been uncommonly associated with human diseases, including meningitis, urinary tract infection, endophthalmitis, splenic abscess, septic arthritis, empyema, ventilatorassociated pneumonia, catheter-associated bacteremia and peritonitis. S. paucimobilis rarely affects immunocompetent patients. It is an uncommon pathogen for PD-related peritonitis, and clinical outcomes in the cases reported so far have varied, with some cases responding to antibiotic therapy alone (5–11) whereas others have eventually required catheter removal (approximately 50%) (4,5,12–14). Literature about peritonitis and treatment caused by Sphingomonas species in PD patients is very limited (Table 1). In our patient, response to antibiotic treatment was excellent, with no eventual catheter loss or relapse. The International Society for Peritoneal Dialysis (IPSD) guidelines do not prescribe a definitive antibiotic therapy for S. paucimobilis. This microorganism tends to have unpredictable antibiotic sensitivity, and therefore, no definitive guidelines exist for antimicrobial therapy for Sphingomonas infections (10).

Does the awareness of the patient about the amount of daily salt consumption decrease his/her salt intake?

Received: 19.10.2016 accepted: 11.11.2016 1Bulent Ecevit University School of Medicine, Department of Internal Medicine 2Zonguldak Ataturk Goverment Hospital, Department of Nephrology 3Bulent Ecevit University School of Medicine, Department of Nephrology Yazışma adresi: Muammer Bilici, Bulent Ecevit University School of Medicine, Department of Internal Medicine, Zonguldak e-mail: drmbilici@hotmail.com GİrİŞ

Aspergillus Peritonitis in Chronic Peritoneal Dialysis Patients: Review of the Literature and Report of Two Cases

Abstract Although gram positive bacteriae are the most common causative microorganisms of chronic peritoneal dialysis (CPD) peritonitis, fungi are responsible for 1-15% of all cases. On the other hand, fungal peritonitis episodes may potentially cause serious consequences such as resistance to treatment, extended hospital stay and also a higher probability of death. Fungal peritonitis due to Aspergillus spp is relatively uncommon, but its mortality rate and severity is known to be even higher. It was our aim to conduct a review of the medical literature regarding the treatment and clinical outcome of Aspergillus related CPD peritonitis and to present two cases with Aspergillus related CPD events. Our current knowledge and the outcome of our two cases suggest that, despite the use of recommended therapeutic measures, Aspergi-llus induced fungal peritonitis in CPD patients may still be fatal. Therefore, there is a need for development of more efficient therapeutic approaches including the type, dose and route of antifungal therapy.