Cyclic Pseudoperitonitis Secondary to Endometriosis in a Peritoneal Dialysis Patient

Cloudy peritoneal effluent is most commonly a result of bacterial peritonitis (1-3) and one of the earliest peritonitis signs to appear (4). According to the 2010 update of International Society for Peritoneal Dialysis guidelines, patients presenting with cloudy effluent should initially be diagnosed with peritonitis, with effluent analysis and a culture to follow, and empiric antibiotics should be started (2,5-7). In patients presenting only with cloudy effluent in the absence of other symptoms and signs of peritonitis, it is reasonable to delay the initiation of antibiotics, provided that the effluent is analyzed in a timely manner (8). In the case of culture-negative effluent, other causes of cloudy dialysate should be suspected after atypical infections have been excluded (1). Although culture-negative peritonitis is not uncommon (9), our patient experienced recurrent cloudy effluent, with negative cultures, coinciding with her menstrual period. Fortunately, the association with her menstrual cycle was recognized. A subsequent clinical diagnosis of endometriosis was made, and appropriate therapy led to resolution of the recurrent pseudoperitonitis. The novel feature in this case was that the patient did not present with hemoperitoneum, as previously reported in the literature (10-15). The patient presented in a manner which truly mimicked the usual presentation of bacterial peritonitis, but without other clinical signs of peritonitis beyond the cloudy effluent. Eventually, because of the strong association of those presentations with her menstrual period, conservative management without antibiotics led to complete resolution of the cloudy dialysate bags upon menstrual period cessation. The subsequent use of anti-ovulatory medications as a form of treatment for endometriosis led to complete resolution of the pseudoperitonitis. A review study by Rocklin et al. (10) listed many causes of cloudy effluent. Retrograde menstruation and other gynecologic causes such as ovulation were discussed as a cause of cloudy effluent because of the presence of an increased number of red blood cells. Tse and colleagues (11) reviewed 549 patients on continuous ambulatory peritoneal dialysis for recurrent hemoperitoneum. Most of the cases in women were attributable to retrograde menstruation (11). In a single-center experience and literature review, Greenberg et al. (12) reported that hemoperitoneum in peritoneal dialysis patients was more common in women and that the most common cause was related to menstruation and ovulation. In addition, Blumenkrantz et al. (13) observed hemoperitoneum in 9 of 11 female chronic peritoneal dialysis patients. Those episodes happened exclusively during the time of menstruation. In our case, the absence of other clinical signs of peritonitis, the negative cultures for almost all of the cloudy bags, and the fact that all the episodes coincided with the patient’s menstrual period made the diagnosis of bacterial peritonitis unlikely. Many of the cases and studies that we reviewed identified gynecologic issues such as retrograde menstruation as a cause of visible hemoperitoneum (14,15), and red blood cells were reported in the bloody effluent bags for those patients. In our case, the bags were always cloudy rather than bloody. We are hence reporting a clinical case of endometriosis as an additional cause of recurrent cloudy peritoneal effluent. DISCLOSURES This work received no support or any funding from any source. No author has any financial conflict of interest to declare.

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