Refractory Peritonitis and Small Bowel Ileus: A Case of Encapsulating Peritoneal Sclerosis Secondary to Mycobacterium abscessus Peritonitis

INTRODUCTION: Complications of peritoneal dialysis (PD) such as exit-site infections and PD peritonitis are common reasons for admission to General Internal Medicine wards. Culprit organisms range from typical skin flora to rarer complicated atypical organisms such as non-tuberculous mycobacteria. Encapsulating peritoneal sclerosis (EPS) is a rarer complication of PD characterized by peritoneal inflammation, ileus and fibrosis with high morbidity, few management options, and poor prognosis. CASE DESCRIPTION: We report the case of a patient with a history of end-stage renal disease on peritoneal dialysis who presented with undifferentiated peritonitis and ileus refractory to standard antimicrobial therapy. Subsequent ascitic cultures were positive for Mycobacterium abscessus, and CT imaging was consistent with EPS. To date, EPS secondary to M. abscessus peritonitis has not previously been described. DISCUSSION AND CONCLUSION: This report describes the diagnostic process and treatment offered to this patient and his treatment outcomes over 8 months. It highlights the importance of prompt identification of patients at risk, timely eradication of high-risk pathogens, and transition to haemodialysis to limit morbidity and improve patient prognosis. LEARNING POINTS: Encapsulating peritoneal sclerosis secondary to Mycobacterium abscessus peritonitis has not been described to date. M. abscessus and other non-tuberculous mycobacterial organisms should be suspected in peritoneal dialysis patients who present with refractory peritonitis and ileus. Encapsulating peritoneal sclerosis is an inflammatory phenomenon characterized by peritoneal inflammation, fibrosis and bowel ileus in the setting of peritoneal dialysis or recurrent infectious insults with high-risk organisms. Diagnosis depends on characteristic imaging coupled with compatible clinical symptoms. Treatment involves transition to haemodialysis, infection eradication, immunosuppression and anti-hormonal treatment (e.g., tamoxifen). Despite these options, prognosis remains very poor.