We describe the first case of continuous ambulatory peritoneal dialysis (CAPD)-related peritonitis due to Lactobacillus paracasei. It occurred in a 65-year-old patient with recurrent episodes of peritonitis while he was receiving a prolonged course of intraperitoneal vancomycin. L. paracasei should be considered in the differential diagnosis of pathogens in CAPD-related peritonitis, especially in patients receiving prolonged vancomycin or glycopeptide treatment. CASE REPORTA 65-year-old diabetic male with end-stage renal disease commenced continuous ambulatory peritoneal dialysis (CAPD) in March 1999. In July 2001, he first reported abdominal discomfort and cloudy dialysate but no fever. Physical examination demonstrated a benign abdomen with a normal-appearing catheter exit site. Peritoneal fluid dialysate was hazy in appearance (white blood cell [WBC] count of 2,040/l, with 96% segmented neutrophils). Therapy with intraperitoneal aztreonam and vancomycin was initiated. Peritoneal fluid culture grew methicillin-resistant Staphylococcus haemolyticus. The patient finished a 2-week course of vancomycin with good results. Shortly thereafter (at the end of August 2001), he developed another episode of CAPD-related peritonitis (peritoneal fluid WBC count of 500/l, with 90% segmented neutrophils). This time, the peritoneal fluid Gram stain showed gram-positive cocci in chains and the culture grew alpha-hemolytic streptococcus species, not enterococcus species. He was given an additional 4 weeks of intraperitoneal vancomycin, during which his abdominal complaints and peritoneal fluid pleocytosis worsened (WBC count increased to 3,200/l, with 80% segmented neutrophils, 5% lymphocytes, and 15% monocytes). Peritoneal fluid cultures during this period revealed diphtheroids and alpha-hemolytic streptococcus species, not enterococcus species. Due to nonclearing of the peritoneal dialysate and ongoing abdominal discomfort, vancomycin was stopped and he received oral levofloxacin and intraperitoneal ceftriaxone, with mild improvement. In early October 2001, the peritoneal fluid analysis showed a WBC count of 784/l (97% segmented neutrophils and 3% monocytes), and culture grew methicillin-resistant Staphylococcus simulans; he was restarted on intraperitoneal vancomycin and continued oral levofloxacin. Two weeks later, on 18 October 2001, the peritoneal fluid analysis revealed a WBC count of 126/l, with 21% segmented neutrophils, 16% lymphocytes, 61% monocytes, and 2% eosinophils, and culture grew a Lactobacillus species, later identified as Lactobacillus paracasei. Antibiotics were stopped at that point, with the assumption that the mild cloudy dialysate effluent represented chemical peritonitis. However, he continued to have abdominal discomfort and started becoming hypotensive. Intraperitoneal vancomycin and aztreonam were started. He was later admitted to the hospital. Repeat peritoneal fluid analysis (9 November 2001) revealed a WBC count of 325/l (21% segmented neutrophils, 16% lymphocytes, 61% monocytes, and 2% eosinophil...
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