CLOUDY BAG: NOT ALWAYS PERITONITIS

V KHELGI1, 2 A GUPTA1, 2,

1Renal unit, Toowoomba Hospital, Toowoomba, Queensland; 2Rural School of Medicine, University of Queensland Toowoomba, Queensland

Background: Chylous ascitis (CA) in peritoneal dialysis (PD) patients is a very rare complication. Due to its milky appearance, it can be confused with peritonitis. There are case reports of CA in patients on PD associated with drugs (calcium channel blockers, everolimus), infections (tuberculosis), malignancy and anatomic disruptions to chyle-containing lymphatic channels. We present a case of a young male who developed CA after insertion of right internal jugular Permcath and resolved completely after removal of the same with no further recurrences.

Case Report: A 23 year-old male acutely developed abdominal discomfort after right internal jugular Permcath insertion. His background includes end stage kidney disease secondary (ESKD) to CAKUT and solute failure on PD. As tenckhoff catheter was in situ, fluid was drained and sent for analysis. He was commenced on IP antibiotics as per the protocol. Initial cell count was high (196, with predominant mononuclear cells) but the repeat counts were down to 5 cells. However the bags continued to be very cloudy and had unusual milky appearance. Triglyceride levels was high consistent with CA (2.3 mmol/L).  There were no eosinophils in the dialysate fluid and Quantiferon gold test was negative. CT chest/abdomen/pelvis did not reveal any blockages. Permcath tip was located appropriately. Lymphscintigram also did not reveal any blockages. After further discussions with patient; Permcath was removed and is back on PD since then. Since the removal of the catheter, PD dilysate bags have been clear with reduced triglyceride levels.

Conclusion: CA is an extremely rare complication in the setting of PD and remains an important differential diagnosis in patients presenting with cloudy bag.

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