Culture-negative peritonitis secondary to splenic infarcts in peritoneal dialysis: Case report and literature review

This case report describes a 66-year-old male on continuous cycling peritoneal dialysis (PD) with polycythemia vera and type 2 diabetes. He presented with culture-negative PD-associated peritonitis secondary to splenic infarcts and further accompanied by a splenic vein thrombosis and posterior brain circulation infarcts. His abdominal pain was atypical for peritonitis, being mild and localized to the left side, with an unremitting course despite several treatment attempts with appropriate antimicrobial coverage. An extensive workup for thromboembolic causes was unremarkable. Initially, the patient was started on aspirin and later treated with hydroxyurea and long-term warfarin. His PD catheter was removed due to concerns about an underlying biofilm, and a new one was inserted one month later, while on temporary hemodialysis, without recurrence. This case highlights that non-infectious, culture-negative PD peritonitis related to splenic infarction should be considered in patients with left-sided abdominal pain, poor clinical response to appropriate antibiotics and significant risk factors for thromboembolic events, such as hematologic disorders like polycythemia vera and splenomegaly. Maintaining a high clinical suspicion can prevent unnecessary antibiotic use and reduce repeated exposure to intravenous contrast for imaging studies. Early initiation of long-term anticoagulation might also prevent futile PD catheter removal if subsequent clinical improvement is obtained.