Viral etiologies, such as herpes simplex virus (HSV), for peritonitis can be misclassified as culture negative peritonitis because of poor accessibility of viral testing in the effluent fluid. Inaccurate diagnosis and subsequent ineffective treatment can lead to unnecessary catheter removal for presumed refractory peritonitis. Here, we report a 73-year-old woman with a history of genital HSV-2 on continuous cyclic peritoneal dialysis who presented with HSV-2 related peritonitis. She initially presented with hypotension, suprapubic pain, and cloudy effluent with an elevated white blood cell count preceded by a 1-week history of genital lesions. Elevated cell counts were primarily lymphocyte and monocyte predominant. Bacterial and fungal cultures were negative, and she had minimal improvement in cell counts after 1 week of empiric antibiotics. Effluent was positive for HSV-2. Acyclovir was reconstituted in a 2.5% Dianeal bag and administered via the intraperitoneal route for local effects and avoidance of neurotoxicity. Her cell counts normalized within a week of starting intraperitoneal antiviral therapy and repeat effluent was negative for HSV at 2 weeks. There is one case report describing HSV-2 related peritonitis
however, to our knowledge, this is the first case of viral peritonitis treated with IP acyclovir successfully.