Peritoneal Dialysis-associated Peritonitis: Early Detection with ¹⁸F-Fluorodeoxyglucose PET/CT

The diagnosis of peritoneal dialysis (PD)-associated peritonitis requires any two of the following features: (a) Clinical features consistent with peritonitis, i.e., abdominal pain or cloudy dialysis effluent; (b) dialysis effluent white cell count >100/μl (after a dwell time of at least 2 h), with >50% neutrophils; and (c) positive dialysis effluent culture.^[1] Whenever peritonitis is suspected, PD effluent should be tested for differential cell count, Gram stain, and bacterial culture.^[1] Conventional imaging (ultrasound, computed tomography [CT]) has a limited role in the diagnosis of PD-associated peritonitis because their findings are often nonspecific^[2] tuberculous peritonitis is common in these patients due to immunosuppression, and it can be detected efficiently with ¹⁸F fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT [Fig 1], though peritoneal carcinomatosis is a known cause of false-positive results.^[3] Prompt clinical diagnosis and early initiation of antibiotic therapy are key to successful treatment, but at the firststages of infection and/or after prolonged antibiotic therapy, typical clinical symptoms can be absent, and PD effluent culture can be sterile,^[1] as it happened in our case. To the best of our knowledge, this is the first report of the detection of nontuberculous PD-associated peritonitis with ¹⁸F FDG PET/CT imaging.

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Fig 1: Maximum intensity projection (MIP) positron emission tomography (PET) image (a) Demonstrates the presence of several hypermetabolic foci located within the abdominopelvic cavity. It must be noted that whole body MIP image does not show usual fluorodeoxyglucose biodistribution, as there is no renal or urinary bladder uptake, most likely due to nonfunctional kidneys. (b) Transaxial PET, (c) Computed Tomography (CT) and (d) fused PET/CT images reveal free abdominopelvic fluid, with high metabolic activity in right iliac fossa (arrows in c and d). Several hypermetabolic lesions are found as well in the peritoneal membrane next to some intestinal loops, with highest metabolic activity located in the left iliac fossa (maximum standarised uptake value - 16.64), (e) as shown in transaxial PET, (f) CT and (g) fused PET/CT images (arrowheads in e and g). Based on these findings and given the patient’s clinical signs, bacterial peritonitis secondary to peritoneal dialysis was suspected, and ultimately confirmed by peritoneal fluid culture

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