Successful Therapy of Scleros

To the Editor: A 43-year-old white male was admitted to the

hospital with recurrent nausea, vomiting, diarrhea, and weight loss. The patient had been treated with chronic hemodialysis for 3 months after failing per- itoneal dialysis for recurrent peritonitis. Culture- proven etiologies of his peritonitis included Staphy- lococczis aureus. Previous evaluation of the patient’s complaints had revealed only erosive esophagitis. On this occasion, upper gastrointestinal and small bowel barium studies revealed a markedly distended stom- ach and small bowel except for those portions in the true anatomic pelvis. Sigmoidoscopy was attempted but could not be accomplished beyond 25 cm be- cause of external constriction. Greenish stool was identified, but all cultures for enteric pathogens were negative, as was the C dificile toxin assay.

The patient underwent exploratory laparotom y to rule out intestinal obstruction. He was noted to have a markedly contracted peritoneal cavity. The parietal and visceral peritonea were covered with a peel of fibrous exudate from 3 to 6 mm in thickness. The visceral organs were indistinguishable in a grayish mass. This thick peel was removed as much as possible to separate the bowel from other organs. A

ng Peritonitis

portion of the membrane was submitted for pathol- ogy, which revealed “reactive fibrous connective tis- sue membrane.”

The postoperative diagnosis was sclerosing peri- tonitis, and the patient was started on tamoxifen 10 mg p.0. twice a day. The patient was maintained on total parenteral nutrition (TPN) in the hospital and was discharged on intradialytic TPN, tolerating small amounts of oral feedings. He has now survived for 6 months and his weight has increased from a low of 108 pounds in the hospital to 170 pounds currently. The patient is now off intradialytic TPN and main- taining a serum albumin of 3.6 mg/dl on oral intake.

This dramatic case may indicate a better outcome for sclerosing peritonitis patients than previously expected. Because of the small number of patients and the sporadic presentation, it would be difficult to perform an adequate clinical trial with tamoxifen. We encourage physicians to report their experience with tamoxifen for the treatment of sclerosing peri- tonitis.

Murray W. Turner and Jeremiah H. Holleman, Jr. Charlotte, NC

Legionella Pneurnophila Pneumonia in a Chronic Hemodialysis Patient

To the Editor: We read carefully the excellent paper from Van-

herweghen et al. (1) concerning the rarity of Legi- onella pneumophila infections in hemodialysis pa- tients.

We would like to report the case of a male patient, 64 years of age, on dialysis for 14 months due to chronic renal failure secondary to crescentic glomer- ulonephritis (treated unsuccessfully with plasma- pheresis and methylprednisolone pulses). The pa- tient was admitted to our unit in January 1990 with fever and productive cough that had continued for the previous five days. Chest X-ray showed a bilateral interstitial infiltration, and Legionella pneumophila was identified by direct immunofluorescence in the sputum. At the same time, two other patients and a member of the staff of the dialysis unit had pneu- monia. Unfortunately it was not possible to identify the agent in these cases. Therapy with erythromycin orally was effective in all patients. Legionella pneu-

inophila was subsequently isolated in the air condi- tioning system of the dialysis unit, and appropriate measures were undertaken.

Although we are not implying that dialysis patients are more susceptible to Legionella, we report the case of one patient with a proven infection, probably included in a surge of Legionella infection in a dialysis unit.

Pedro Lea0 Neves, Rui Ferreira, Isabel Pinto, Joao P. Amorim ServiCo de Nefrologia Hospital Distrital de Faro Faro, Portugal

Reference 1. Vanhenveghen JL, Tielemans C, Goldman M, Boelart J Infections in

chronic hernodialysis patients. Semin Dial 4240-244, 199 1

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