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Wywołane Przez Kocuria Kristinaeu Chorej

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Wywołane Przez Kocuria Kristinaeu Chorej Forum Nefrologiczne 2019, tom 12, nr 3, 182–186 PRZYPADKI KLINICZNE Copyright © 2019 Via Medica ISSN 1899–3338 Dariusz Szczyra, Władysław Grzeszczak Katedra Chorób Wewnętrznych, Diabetologii i Nefrologii w Zabrzu, Śląski Uniwersytet Medyczny w Katowicach Dializacyjne zapalenie otrzewnej wywołane przez Kocuria kristinae u chorej ze schyłkową niewydolnością nerek leczonej metodą ciągłej ambulatoryjnej dializy otrzewnowej (CADO) Peritoneal dialysis peritonitis induced by Kocuria kristinae in a patient with end-stage renal disease treated with continuous ambulatory peritoneal dialysis (CAPD) neal dialysis treated since February 2018, in which, ABSTRACT one year after the start of this method, the peritoneal dialysis peritonitis was performed, and in the per- Kocuria kristinae is a bacteria that lives on the skin formed culture this rare bacterium was bred. of humans and other mammals, which rarely causes Forum Nefrol 2019, vol 12, no 3, 182–186 infections. However, there are sporadic reports of the peritoneal peritonitis that it causes. Below, we Key words: Kocuria kristinae, peritoneal dialysis, present a case of a 60-year-old woman with perito- peritoneal dialysis peritonitis WSTĘP stinae często rośnie na prostych podłożach, ta- kich jak agar z krwią, w temperaturze 25–37°C. Kocuria kristinae to bakteria z rodziny Mi- Średnica jej komórki wynosi około 0,7–1,1 µm; crococcaceae [1]. Bakteria ta została nazwana tworzy tetrady lub skupiska tetrad. Kolonie od nazwiska jej odkrywcy, słowackiego mikro- mogą być gładkie lub szorstkie, zazwyczaj wy- biologa Miroslava Kocura [2]. Po raz pierwszy pukłe; ich kolor waha się od bladokremowego bakteria ta została wyizolowana z pałki wąsko- do bladopomarańczowego [7]. Kocuria wy- Adres do korespondencji: listnej [3]. Jest to Gram-dodatnia, katalazodo- stępuje najczęściej na skórze, błonie śluzowej dr Dariusz Szczyra datnia, koagulazoujemna bakteria z gromady jamy ustnej i na innych błonach śluzowych. Zo- Katedra Chorób Wewnętrznych, Actinobacteria, rzędu Actinomycetales, rodziny stała ona również wykryta w drogach moczo- Diabetologii i Nefrologii w Zabrzu Micrococcaceae, rodzaju Kocuria [4–6]. Ogó- wych chorych z zakażeniem układu moczowe- Śląski Uniwersytet Medyczny w Katowicach ul. 3 Maja 13–15, 41–800 Zabrze łem opisano siedemnaście gatunków Kocuria, go [8]. Kocuria kristinae jest często izolowana e-mail: [email protected] a wśród nich Kocuria kristinae [1]. Kocuria kri- z kiełbas i innych produktów mięsnych. 182 Istnieje jednak coraz więcej doniesień krwinek (RBC, red blood cells) 2,74 × 106/µl]. vvIstnieje coraz więcej sugerujących zakażenia inwazyjne K. kristinae, Pleocytoza w płynie z jamy otrzewnowej wy- doniesień sugerujących zwłaszcza u chorych leczonych immunosupre- nosiła 1320/3. Włączono empiryczną antybio- zakażenia inwazyjne syjnie, u chorych na nowotwory złośliwe lub tykoterapię (ceftazydym 2 × 1 g i.v., następ- K. kristinae, zwłaszcza u bardzo małych dzieci [8, 9]. Bakteria ta może nie 4 × 250 mg i.v., cyprofloksacyna 100 mg u chorych leczonych wywoływać ostre zapalenie pęcherzyka żółcio- 1 × dziennie i.v.) oraz zlecono heparynę nie- immunosupresyjnie, wego, wsierdzia, ropne zapalenie stawów czy frakcjonowaną 1000 j. co 6 godzin dootrzew- u chorych na też zapalenie otrzewnej u chorych leczonych nowo. Pobrano płyn z jamy otrzewnowej oraz nowotwory złośliwe dializą otrzewnową (CADO) [10–13]. mocz na badanie bakteriologiczne. lub u bardzo małych Znane są antybiotyki bakteriobójcze zwal- W wykonanym posiewie płynu dializa- dzieci. Bakteria ta może czające tę bakterię, jednak zalecenia dotyczące cyjnego uzyskano wzrost bakterii Kocuria kri- wywoływać ostre leczenia zakażeń Kocuria kristinae nie zostały stinae wrażliwej na amikacynę, gentamycynę, zapalenie pęcherzyka jeszcze zdefiniowane. W większości opubliko- cyprofloksacynę, lewofloksacynę, erytromy- żółciowego, wsierdzia, wanych badań wskazuje się, że K. kristinae jest cynę, teikoplaninę, tetracyklinę, tigecyklinę, ropne zapalenie wrażliwa na wiele antybiotyków (wankomycy- trimetoprim z sulfametoksazolem oraz wan- stawów czy też na, linezolid, ryfampicyna, teikoplanina, cefo- komycynę. Rozpoczęto celowaną antybiotyko- zapalenie otrzewnej taksym, ampicylina/sulbaktam i meropenem). terapię wankomycyną z regularną kontrolą jej u chorych leczonych Wankomycyna jest najczęściej stosowanym stężenia w surowicy. W kolejnych badaniach dializą otrzewnowącc antybiotykiem w leczeniu tego zakażenia [14]. kontrolnych obserwowano wartości pleocy- W niniejszej pracy przedstawiono przypa- tozy maksymalnie 4167/3, a następnie spa- dek chorej ze schyłkową niewydolnością nerek dek do 189/3 oraz obniżenie stężenia CRP z dializacyjnym zapaleniem otrzewnej wywoła- w surowicy do 53,29 mg/l oraz leukocytozy do 3 nym przez Kocuria kristinae. 5,35 × 10 /µl. Chorej przetoczono również 8 j. vvW większości koncentratu krwinek czerwonych, uzyskując opublikowanych badań OPIS PRZYPADKU wzrost stężenia Hb do 9,7 g/dl, Ht do 30,3 g/dl wskazuje się, że 6 oraz liczby erytrocytów 3,61 × 10 /µl. K. kristinae jest Na Oddział Nefrologiczny Kliniki Chorób Po 20 dobach antybiotykoterapii zlecono wrażliwa na wiele Wewnętrznych, Diabetologii i Nefrologii SUM pierwszy kontrolny posiew płynu dializacyjne- antybiotyków w Zabrzu w dniu 13.02.2019 została przyjęta go, w którym nie uzyskano wzrostu patogenów (wankomycyna, 60-letnia chora na cukrzycę typu 2 i nadciśnie- chorobotwórczych. Kolejny posiew wykonano linezolid, ryfampicyna, nie tętnicze, z otyłością, z przewlekłą choro- w 26. dobie antybiotykoterapii, również uzysku- teikoplanina, bą nerek w stadium G5. U chorej od lutego jąc posiew jałowy. W 29. dobie hospitalizacji cefotaksym, 2018 roku rozpoczęto leczenie nerkozastęp- odstawiono wankomycynę. Pacjentka nie zgła- ampicylina/sulbaktam cze. W okresie 15.02–15.03.2018 pacjentkę szała dolegliwości, nie gorączkowała, utrzymała i meropenem). hemodializowano. W dniu 28.02.2018 wszcze- się pleocytoza < 100/3. Stan kliniczny chorej był Wankomycyna piono cewnik Tenckoffa, od 6.03.2018 u chorej dobry. Planowano wypis do domu. jest najczęściej rozpoczęto zaś leczenie metodą CADO. Niestety, w 35. dobie hospitalizacji stan stosowanym Chora została przyjęta na Oddział Nefro- kliniczny pacjentki się pogorszył. Wykonano antybiotykiem logiczny Kliniki Chorób Wewnętrznych, Dia- kolejny posiew dializatu, wyhodowano Strep- w leczeniu tego betologii i Nefrologii SUM w Zabrzu z powo- tococcus salivarius wrażliwy na klindamycynę, zakażeniacc du znacznego osłabienia, nudności, wymiotów, erytromycynę, lewofloksacynę, tigecyklinę, braku apetytu, z cechami odwodnienia oraz hi- wankomycynę oraz teikoplaninę. Rozpoczę- potonii (ciśnienie tętnicze 80/40 mm Hg) oraz to leczenie teikoplaniną w dawce 3 × 66 mg bólu brzucha. W wywiadzie odnotowano wy- dootrzewnowo, a po 8 dobach utrzymującego stępujący od kilku tygodni kaszel z odkrztusza- się wysokiego miana pleocytozy dawkę leku niem zielonkawej plwociny. Dializat po wymia- zwiększono do 3 × 100 mg dootrzewnowo. nie był mętny o żółtawym zabarwieniu. Miesiąc W 46. dobie pobrano posiew dializatu; nie uzy- wcześniej chora była leczona z powodu zakaże- skano wzrostu patogenów chorobotwórczych, nia układu moczowego cyprofloksacyną. jednak pleocytoza wynosiła 879/3. W kolejnych W badaniach dodatkowych u pacjent- dobach utrzymywały się wysokie miana pleocy- ki stwierdzono wysokie wartości parametrów tozy. W 55. dobie hospitalizacji zadecydowa- stanu zapalnego [stężenie białka C-reaktyw- no o zakończeniu leczenia nerkozastępczego nego (CRP, C-reactive protein) 206 mg/dl], metodą dializy otrzewnowej, usunięto cewnik leukocytozę (11,2 × 103/µl) oraz niedokrwi- Tenckhoffa. W 57. dobie założono czasowy stość normocytarną [hemoglobina (Hb) 7 g/dl, cewnik hemodializacyjny do prawej żyły szyj- hematokryt (Ht) 22,8%, poziom czerwonych nej wewnętrznej i rozpoczęto leczenie hemo- Dariusz Szczyra, Władysław Grzeszczak, Dializacyjne zapalenie otrzewnej wywołane przez Kocuria kristinae 183 dializami. Chora kontynuuje tę formę leczenia wodu schyłkowej niewydolności nerek metodą pod kontrolą macierzystej stacji dializ. Zapla- CADO. W posiewie płynu z jamy otrzewnowej nowano ocenę możliwości powrotu do leczenia chorego stwierdzono obecność Kocuria kristi- metod dializy otrzewnowej za 3 miesiące. nae. Leczenie rozpoczęto od podania cefotak- symu (cefalosporyna III generacji) oraz tobra- DYSKUSJA mycyny (aminoglikozyd) (przez 48 godzin), a następnie po uzyskaniu wyników posiewu Na Oddział Nefrologiczny Kliniki Cho- z jamy brzusznej dootrzewnowo podawano cy- rób Wewnętrznych, Diabetologii i Nefrologii profloksacynę (chinolon II generacji — fluoro- trafiła 60-letnia letnia chora ze schyłkową nie- chinolol) z teikoplaminą (naturalny antybiotyk wydolnością nerek, leczona metodą CADO, glikopeptydowy, podobny do wankomycyny, z zapaleniem otrzewnej. Najczęściej izolowa- o silnych właściwościach lipofilnych) oraz do- nymi patogenami będącymi przyczynami zapa- żylnie amoksycyliną z kwasem klawulonowym. lenia otrzewnej są Staphylococcus aureus i inne Postępowanie terapeutyczne zakończyło się koagulazoujemne gronkowce, które należą sukcesem — chory wyzdrowiał. do flory fizjologicznej bytującej na skórze [9]. Cheung i wsp. [16] opisali z kolei mężczy- Dializacyjne zapalenie otrzewnej należy podej- znę w wieku 69 lat, leczonego z powodu schył- rzewać zawsze, gdy chory zgłasza bóle brzucha kowej niewydolności nerek metodą CADO. lub wyciek mętnego płynu. Rozpoznanie ustala W posiewie płynu z jamy otrzewnowej chorego się, kiedy spełnione są dwa z trzech kryteriów: również stwierdzono
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