sclerosing peritonitis ( sp ) is a rare form of peritoneal inflammation which involves both the visceral and the parietal surfaces of the abdominal cavity . it is characterized by a fibrous thickening and sclerotic changes of the peritoneum and is reported to complicate peritoneal dialysis ( pd ) in most cases . furthermore , small bowel obstruction due to adhesions and encapsulation with abdominal pain , anorexia , nausea , and vomiting is frequently observed and ultimately entails weight loss and malnutrition . we describe the case of a 28-yr - old man with end - stage renal disease on pd showing fulminant sp presented like acute culture - negative peritonitis and successfully treated with corticosteroid therapy . on review of the literature , there have been only a few case reports where the presentation of sp has been dominated by an acute inflammatory state ( 3 - 7 ) . there was a delay in diagnosis due to the rare mode of presentation , and also a delay in commencement of appropriate therapy . a high degree of clinical suspicion is necessary to diagnose this form of sp , and initiate corticosteroid therapy which appears particularly effective for fulminant sp ( 1 , 7 ) . a 28-yr - old man had been maintained on continuous ambulatory peritoneal dialysis ( capd ) for 6 yr due to end - stage renal disease of unknown etiology . he used baxter capd system and dialysate with lactate as the base . in december 2011 , he had first episode of uncomplicated peritonitis by methicillin - sensitive staphylococcus epidermidis , which was treated with intraperitoneal cefazolin . on april 06 , 2012 , he was admitted due to diffuse abdominal pain which had developed 5 days before admission . at the time of admission , blood pressure was 143/77 mmhg , body temperature 36.4 , height 155 cm , and weight 39 kg . laboratory tests showed the following : hemoglobin 12.4 g / dl , hematocrit 35.6% , leukocyte count 8,540/l with neutrophil 86.4% , platelet 219,000/l , c - reactive protein ( crp ) 5.17 mg / dl , blood urea nitrogen 74.5 mg / dl , serum creatinine 16.59 mg / dl , glucose 184 mg / dl , cholesterol 181 mg / dl , total protein 8.2 g / dl , albumin 4.0 g / dl , ast 19 u / l , alt 23 u / l , total bilirubin 0.42 mg / dl , alkaline phosphatase 258 iu / l , ck 96 u / l , ldh 411 u / l , amylase 7 u / l , lipase 42 u / l , and peritosol leukocyte count 66/l with neutrophil 75% . on the fifth hospital day , crp remained high ( 6.05 mg / dl ) and peritosol leukocyte count was 297/l with neutrophil 90% . repeat cultures were all negative for bacteria , fungi , and mycobacteria . despite numerous antimicrobial agents , diffuse abdominal pain persisted and peritosol leukocyte count remained high ( 594/l with neutrophil 57% ) . on the eleventh hospital day , pd catheter was removed , and he was switched to hemodialysis . nevertheless , his condition deteriorated . on the twenty - first hospital day , computed tomography ( ct ) scan of the abdomen ( fig . on the twenty - third hospital day , oral prednisolone was prescribed at a dose of 40 mg / day ( 1.0 mg / kg / day ) on the diagnosis of fulminant sp . on the next day after corticosteroid therapy crp decreased significantly from 19.49 mg / dl to 6.75 mg / dl ( fig . 1b ) showed decreased amount of ascites without significant change of peritoneal thickening . in august 2012 , he is still free of abdominal pain with a dose of 10 mg / day of oral prednisolone . sp is a rare form of peritoneal inflammation which is reported to occur as an idiopathic form or secondary form in association with long - standing pd , prior abdominal surgery , recurrent peritonitis , and beta - blocker ( practolol ) treatment . the continual exposure to nonphysiologic pd solutions and intermittent peritonitis are probable precipitants for the development of sp , with the duration of pd being the most relevant single factor ( 1 , 8) . nonphysiologic pd solutions such as high concentrations of glucose and lactate , low ph , and bioincompatible substances may induce a chronic sterile inflammation in the peritoneal membrane with upregulation of several cytokines resulting in collagen synthesis by mesothelial cells and fibroblasts ( 2 ) . moreover , they can directly damage the peritoneal membrane , and might contribute to the development of sp . simple peritoneal sclerosis ( ss form ) is a mild fibrosing condition of the peritoneal membrane that appears in most patients after several years of pd . the sp form is a dramatic progression of the sclerosis after an inflammatory insult , such as peritonitis . the sclerotic tissue is thicker than in ss , and a marked chronic inflammatory infiltrate is present ( 9 ) . in a small minority , these sclerotic changes the severe sp like this has been termed sclerosing encapsulating peritonitis ( sep ) or encapsulating peritoneal sclerosis ( eps ) ( 1 ) . inflammatory stage with manifestations of fever , increased crp levels , and ascites develop several weeks or months after the removal of a pd catheter . steroid therapy is recommended during the early stage . if the eps with ileus symptoms is not relieved or recurs within 1 month , steroid dose reduction and total parenteral nutrition ( tpn ) if ileus symptoms remain despite the absence of inflammatory manifestations , laparatomy and enterolysis is considered at this ileus stage . with the increasing number and survival of pd patients , sp becomes an important problem . estimated prevalence of sp is reported to be 0.5%-0.9% of pd patients ( 1 , 8 , 10 , 11 ) . sp usually occurs in patients receiving pd for more than 4 - 5 yr , and most sp patients have a past medical history of infectious peritonitis . the common manifestations are ultrafiltration and clearance failure in pd patients , abdominal pain , anorexia , nausea , vomiting , weight loss and malnutrition . these reflect fibrous thickening of the peritoneal membrane , inhibition of peristalsis , encapsulating sclerosis and small bowel obstruction . the fulminant form of sp like this is rare , but it can occur as a second phase phenomenon immediately following acute bacterial peritonitis ( 7 ) . in our case , a fulminant sp may present like or develop immediately following acute culture - negative peritonitis . diagnosis of sp is made by clinical and radiological methods such as ct scanning , or by surgical laparotomy with excision of sclerosed peritoneum . histopathology is now seldom required as ct scanning with the clinical features can make a diagnosis of sp . sp should be considered in any patient on prolonged pd who develops recurrent abdominal pain or bowel obstruction in the absence of active infectious peritonitis . the combined ct imaging features of peritoneal enhancement , calcification , and thickening , bowel wall thickening , loculated fluid collections , and tethered small bowel loops in this clinical setting should be considered diagnostic of sp ( 1 , 12 ) . in our case , sp was diagnosed by the ct findings of peritoneal enhancement and thickening , bowel wall thickening , mesenteric thickening with nodularity , and ascites even after pd catheter removal in the clinical setting of acute sterile peritonitis developed in pd patient . treatment of secondary sp in pd patient depends on the severity of symptoms at the time of presentation . it includes cessation of pd , change to hemodialysis , nutritional support , tamoxifen , immunosuppressive therapy ( 9 , 13 - 15 ) , and surgery . intestinal enterolysis can be performed if intestinal obstruction symptoms are not improved by steroid administration or tpn ( 4 , 16 ) . anti - fibrotic agent , such as tamoxifen , may have been used without significant benefit . the benefit with immunosuppressive agents in the previous case reports was variable according to drug chosen , clinical features , and treatment timing . corticosteroid therapy may be effective for an acute inflammatory state of fulminant sp ( 3 , 4 , 7 , 13 ) . in our case , acute sterile peritonitis of fulminant sp once eps with ileus symptoms have appeared , mortality is extremely high due to illness related to bowel obstruction or complications of surgery . ct scanning should be considered in the patient with the presence of clinical manifestations suspicious for sp .
sclerosing peritonitis is an uncommon complication of peritoneal dialysis . 
 it is characterized by peritoneal fibrosis and sclerosis . 
 the most common clinical presentations of sclerosing peritonitis in peritoneal dialysis patients are ultrafiltration failure and small bowel obstruction . 
 the prognosis and response to immunosuppressive therapy of sclerosing peritonitis presenting with ultrafiltration failure or small bowel obstruction are poor . here 
 , we describe the case of a 28-yr - old man with end - stage renal disease on peritoneal dialysis showing fulminant sclerosing peritonitis presented like acute culture - negative peritonitis and was successfully treated with corticosteroid therapy . 
 it is not well recognized that sclerosing peritonitis may present in this way . 
 the correct diagnosis and corticosteroid therapy may be life - saving in a fulminant form of sclerosing peritonitis .