Ekart et al. Journal of Medical Case Reports 2012, 6:309 http://www.jmedicalcasereports.com/content/6/1/309 dialysate, and abdominal pain in the upper abdomen as well as diarrhea. On admittance, he was afebrile and normotensive with a blood pressure of 125/85mmHg; his pulse was regular but tachycardic at 143 beats per minute. There was no abdominal tenderness. The PD catheter exit site was clean. An electrocardiogram (ECG) showed sinus tachycardia with a rate 143 beats per minute, but no signs of myocardial ischemia were seen. The complete blood count showed white blood cells of 14.6 cells/mm3 with 83% segmented neutrophils, 1% unsegmented neu- trophils, 7% lymphocytes, 7% monocytes, and 2% eosi- nophils; hematocrit 33%; and platelets of 313 × 103/μL. C-reactive protein was 138mg/L and procalcitonin was 1.1ng/mL. The first dialysate leukocyte count was 1055/μL with 93% segmented neutrophils, 3% lymphocytes and 4% monocytes. The usual PD-related peritonitis was suspected and after sending the first PD effluent for culture to the la- boratory, we started treatment with antibiotics according to hospital protocol: intra-peritoneal cefazoline and ceftazi- dime. The Gram stain of the first effluent was negative. The second Gram stain of the PD effluent 3 days after admit- tance was also negative. The exit site culture and coprocul- ture were negative. The abdominal X-ray and abdominal ultrasound (US) were unrevealing. After 3 days of antibiotic therapy the clinical status of the patient did not improve. Furthermore, abdominal tenderness in the epigastrium and the upper right quadrant, inappetence and anuria, appeared. The patient was switched to hemodialysis using a Page 2 of 4 central venous catheter in the vena jugularis interna. On the sixth day after admission the patient complained, for the first time, about pain in his left arm; his ECG was with- out signs of ischemia, and his troponin T was slightly ele- vated (0.19μg/L). On the seventh day after admission we decided to remove the peritoneal catheter in a surgical pro- cedure under general anesthesia. The dialysate leukocyte count just before the operation was 4385/μL with 99% seg- mented neutrophils. After the surgical procedure the pa- tient was treated with intravenous vancomycin and ceftazidime, but over the next few days his clinical situation was no better (severe abdominal pain with nausea and vomiting). On the 11th day the patient complained of pain in both arms; on the ECG signs of ischemia (T-wave inver- sion in inferior leads) were found. The troponin T on the same day was 1.13μg/L (Figure 1 shows the enzymatic curve) and non-ST elevation myocardial infarction was sus- pected. Regarding this clinical condition a cardiologist was consulted about a coronarography and an abdominal sur- geon about a relaparotomy. On the same day a decision was made for surgery to be carried out. Surgeons per- formed an explorative laparotomy and found diffuse peri- tonitis and gangrenous appendicitis. An appendectomy was performed. The patient was admitted to the intensive care unit. Mechanical ventilation support was needed. The next day on an ECG ST elevation in the anterior wall was present, and troponin T was 6.22μg/L; the echocardiog- raphy showed hypokinetic anteroapical wall of the left Figure 1 Enzymatic curve for troponin T.