Ekart et al. Journal of Medical Case Reports 2012, 6:309 http://www.jmedicalcasereports.com/content/6/1/309 ventricle, the ejection fraction was 40%. The patient was treated with vasopressors, intravascular antibiotics and anti- mycotic therapy with vancomycin, imipenem-cilastatin and fluconazole. On the 15th day of admission paralytic ileus appeared. A relaparotomy and an ileostomy were per- formed. After this operation the patient improved. He was extubated, lucid and talking. On the 17th day of admission the patient became worse again, he was hypotensive, in shock, and between vomiting he aspirated. On the 19th day of hospitalization bradycardia developed and cardiopul- monary resuscitation was performed. On the 20th day of admission the patient died of septic-toxic shock and multi- system failure. Discussion In the medical literature 16 cases of appendicitis in adult patients on PD have been reported to date [1-11]. Most patients survived. Only one patient, a 46-year-old man, has died [1]; the reason was septic shock. Our case is the second with a fatal outcome but the first in which the pa- tient suffered from acute myocardial infarction that influ- enced the postoperative clinical course and final outcome. The presented case shows that a clinical presentation of abdominal pain in patients on PD deserves maximal at- tention and careful differential diagnosis on admittance to hospital. To find intra-abdominal pathology in these patients can be very difficult because the common cause of acute abdominal pain in PD patients is peritonitis caused by exogenous infection related to the peritoneal catheter. In our patient the delay in diagnosis of appendi- citis was 10 days and it was consistent with the delays of between 2 and 27 days reported by others [1,2]. There are many reasons for a delay in diagnosis. The patients presented with symptoms of abdominal pain complained about diffuse pain and failed to localize the pain to a specific quadrant and thus raised the suspicion of appendicitis, perforation, diverticulitis and so on [1]. The treatment with intra-peritoneal antibiotics is indi- cated in PD peritonitis. Unfortunately, in PD patients with intra-abdominal pathology intra-peritoneal antibio- tics probably dilute the bacterial load, retard abscess for- mation and also protract the course of the clinical picture [1]. The cultures of peritoneal fluid in patients with intra-abdominal pathology, especially before perfor- ation, are often negative, and it can take several days to reveal multiple enteric Gram-negative organisms. In 13 out of 16 reported cases, the Gram stain of the periton- eal fluid was negative. In the positive cultures of periton- eal fluid mostly Bacteroides species and Escherichia coli were isolated. In our case, the patient did not complain of localized abdominal pain; the two cultures of periton- eal fluid were also negative, the second probably because of the intra-peritoneal antibiotic treatment. We also speculated that the delay in diagnosis was due to masked Page 3 of 4 abdominal signs and direct local instillation of antibio- tics in peritoneal fluid on the inflammatory appendix. The patient complained about pain in his arms, troponin T was elevated, and ECG changes were found. This cor- onary incident also had some influence on the post- operative complications, sepsis and fatal outcome. Before the surgical procedure, two abdominal USs were performed. Unfortunately, no computed tomography (CT) scan of the abdomen was performed. The sensitivity of abdominal US and CT as diagnostic tools in appendi- citis in PD patients is rather doubtful. Carmeci et al. [1], Yang et al. [3] and Yehia et al. [4] reported that abdom- inal CT scanning is not a sensitive diagnostic tool in the evaluation of these patients [1,3]. Mihout et al. consider that the CT scan represents a diagnostic test of choice [5]. Yehia et al. reported that a laparotomy was typically delayed because of negative findings on CT [4]. Carmeci et al. concluded in their series of six patients that the negative imaging added to the delay in diagnosis and treatment of serious intra-abdominal infections [1]. The non-localizing physical examination and negative or non-specific results of an abdominal CT scan do not rule out serious intra-abdominal disease [6]. On the basis of these different conclusions about the CT scan it can be said that a negative CT scan does not rule out an ab- dominal complication and should lead to further investi- gations by means of other procedures such as an explorative laparoscopy. According to available data on PD patients, we can conclude that cloudy peritoneal effluent together with abdominal pain is not necessarily PD-related peritonitis. Furthermore, abdominal pain that persists for more than 48 hours after the usual antibiotic protocol for PD- related peritonitis should immediately alert the physician to the possibility of peritonitis caused by intra-abdominal pathology. Conclusions To avoid the unsuccessful treatment of a PD patient with acute abdominal pain as described in this case, an intra-hospital agreement of the treatment strategy be- tween nephrologists and abdominal surgeons was reached. In PD patients whose clinical features worsen or fail to resolve with the established intra-peritoneal anti- biotic therapy not only peritoneal catheter removal is indi- cated but a laparoscopy should be done after 72 hours, and in the case of correct indication (intra-abdominal pathology) an early explorative laparotomy. Consent Written informed consent was obtained from the pa- tient´s next-of-kin for the publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.