A Rare Case of Mycobacterium abscessus Peritoneal Dialysis-Associated Peritonitis

Introduction: M. abscessus is a non-tuberculous mycobacterium commonly transmitted from the environment or from contaminated hospital sources. Successful recovery after treatment for complications arising from M. abscessus infection is low due to antibiotic resistance. We introduce a unique case of M. abscessus emerging from the site of a peritoneal dialysis (PD) catheter. Case Description: A 53-year-old female with HTN, CAD, asthma, OSA, RCC s/p right partial nephrectomy, and ESRD due to diabetic nephropathy presents to ED with abdominal pain from her groin to her back and purulent discharge from her PD catheter site. The catheter was placed 4 months prior and was without significant issues until 3 weeks before presentation when she developed aching pain and a dime-sized hard area around her navel. The patient was initially treated with oral antibiotics, and shortly after, with vancomycin through her PD catheter and Keflex. Despite drainage from the wound site changing from a thick green to a thin yellow, her pain worsened. During this period, her symptoms included fever, chills, nausea, decreased appetite, and constipation. After cultures from the PD catheter tested positive for M. abscessus, she was sent to ED. The PD catheter was removed by Vascular Surgery, and the wound was allowed to heal with a penrose drain left in. The patient began hemodialysis (HD) thrice weekly and was initiated on an antibiotic regimen of 500 mg azithromycin daily, 300 mg omadacycline daily, 500 mg IV imipenem every 12 hours, and amikacin. ID recommended to complete a minimum 12-week course of IV antibiotics, then transition to oral antibiotics to complete 3-6 months of therapy. A peripherally inserted central catheter line was placed for the IV course. On discharge, the patient was recommended to continue 775 mg IV amikacin twice weekly at least 4 hours before HD. Discussion: This case illustrates the complexity of managing complications associated with M. abscessus in PD. The described treatment plan for M. abscessus PD-associated peritonitis highlights the importance of culture-directed antibiotic therapy, particularly that of an amikacin-led regimen. This case additionally emphasizes the need for multiple modalities of dialysis, as removal of the contaminated catheter and proper recovery of the wound site prompted a switch to HD.