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Zygomycetes peritonitis in ambulatory peritoneal dialysis: Case report and review of literature.
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PMID:  25097341     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
We present a case of CAPD peritonitis caused by zygomycetes infection. A 46-year-old male patient presented with refractory peritonitis requiring catheter removal. He had persistence of fever and an ultrasonography abdomen done revealed loculated collections. An initial pigtail drainage followed by open laparotomy was performed. Intra-operative peritoneal and omental biopsy revealed large areas of necrosis with broad aseptate fungal hyphae consistent with zygomycosis. He was managed with 3 gm of intravenous amphotericin and is doing well at 6 months of follow-up.
Authors:
M Rathi; U Sengupta; T D Yadav; S Kumar
Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Indian journal of nephrology     Volume:  24     ISSN:  0971-4065     ISO Abbreviation:  Indian J Nephrol     Publication Date:  2014 Jul 
Date Detail:
Created Date:  2014-08-06     Completed Date:  2014-08-06     Revised Date:  2014-08-08    
Medline Journal Info:
Nlm Unique ID:  8914356     Medline TA:  Indian J Nephrol     Country:  India    
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Languages:  eng     Pagination:  252-4     Citation Subset:  -    
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Journal Information
Journal ID (nlm-ta): Indian J Nephrol
Journal ID (iso-abbrev): Indian J Nephrol
Journal ID (publisher-id): IJN
ISSN: 0971-4065
ISSN: 1998-3662
Publisher: Medknow Publications & Media Pvt Ltd, India
Article Information
Copyright: © Indian Journal of Nephrology
open-access:
Print publication date: Season: Jul-Aug Year: 2014
Volume: 24 Issue: 4
First Page: 252 Last Page: 254
PubMed Id: 25097341
ID: 4119341
Publisher Id: IJN-24-252
DOI: 10.4103/0971-4065.133028

Zygomycetes peritonitis in ambulatory peritoneal dialysis: Case report and review of literature
M. Rathiaff1
U. Senguptaaff1
T. D. Yadav1
S. Kumar2
Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
1Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Correspondence: Address for correspondence: Dr. Manish Rathi, Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012, India. E-mail: drmanishrathi2000@yahoo.co.in

Introduction

Ambulatory peritoneal dialysis is the preferred form of dialysis in countries where the facility of maintenance hemodialysis is limited.[1] Infections in the form of peritonitis, exit site infections and tunnel infections are the most common problems with peritoneal dialysis.[2] Although Gram-positive bacilli are the most common cause of peritonitis, they can also be caused by Gram-negative bacilli, while fungi accounts for about 5-10% cases of peritonitis.[2, 3] Peritonitis secondary to zygomycosis has been reported only as case reports and till date about 16 cases have been reported in the world literature.[4] We report a case of peritonitis secondary to zygomycetes infection, which was managed successfully with the help of surgery and amphotericin B. Earlier, two cases of zygomycetes associated peritoneal dialysis infection have been reported from India;[5, 6] however, both of them succumbed, making our case probably the first from India to have survived this infection.


Case Report

A 46-year-old male with end stage renal disease secondary to IgA nephropathy had been started on continuous ambulatory peritoneal dialysis (CAPD) 6 years back. He was using the Twin Bag system (Baxter HealthCare, McGaw Park, Illinois, USA), and was doing 4 exchanges/day. 3 years after starting on CAPD, he developed an episode of bacterial peritonitis, which was managed successfully with antibiotics. Currently, he presented with 3 days history of severe abdominal pain with high grade fever and turbid effluent. He was started on intravenous (i.v.) meropenem and vancomycin which he received for 48 h before presenting to us. At presentation, he was febrile but hemodynamically stable. The abdomen was diffusely tender; however, the exit site was healthy. His CAPD fluid analysis showed 1050 cells with 75% polymorphs while the fluid culture was sterile. He was continued on same i.v. antibiotics with no response. Repeat CAPD effluent bacterial and fungal cultures, acid fast staining and mycobacterial culture (collected later) were sterile. After 72 h, due to non-response, his CAPD catheter was removed and he was continued on i.v. antibiotics.

Despite these measures, he continued to have high grade fever. At the end of 1 week, an ultrasound (USG) abdomen was done which revealed loculated ascites. A USG guided ascitic tap drained thick pus, following which a pigtail catheter was inserted in the largest of loculi, which failed to drain the collection. Due to persistence of fever and loculated pus collections, he underwent open laparotomy. Intra-operatively, multiple loculated fluid collections with dense adhesions between bowel loops and peritoneum were noted [Figure 1a]. The loculi were broken and about 500 ml of pus was drained. The peritoneal and omental biopsy taken intra-operatively revealed large areas of necrosis along with broad aseptate fungal hyphae consistent with zygomycosis [Figure 1b]. The patient was started on 75 mg/day of i.v. conventional amphotericin B. After 48 h, he started showing response and became afebrile. He received a total of 3 g amphotericin B and was doing fine at 6 months follow-up.


Discussion

Fungal peritonitis, accounts for about 5-10% of CAPD peritonitis across different series.[2, 3] About 80-90% of the episodes are caused by Candida species, while among the filamentous fungi, Aspergillus is the most common.[7] Fungal peritonitis poses a real problem to the nephrologists and mycologists with its relatively high mortality rate (5-15%) and significantly high permanent CAPD discontinuation rate (about 40% patients shifted to hemodialysis).[2, 3] Infection by Zygomycetes group is extremely rare and till date about 16 cases have been described [Table 1]. Risk factors include previous antibiotic use, uncontrolled diabetes mellitus and desferrioxamine therapy. Since our patient was on i.v. antibiotics for about 1 week only, we don’t think that this may be a predisposing factor for development of fungal peritionitis in our case. Due to the same reason, our patient did not receive any antifungal prophylaxis.

The clinical presentation of these patients is not different from an episode of usual bacterial peritonitis with pain abdomen, fever and cloudy effluent, however, these patients fails to improve after adequate empirical antibiotic therapy for suspected bacterial peritonitis. The diagnosis is most cases was made by culturing the organism from the CAPD effluent, however, only in few cases a tissue invasion was documented. In our case, direct tissue invasion was documented and the large amount of tissue necrosis noted was consistent with the capacity for vascular invasion of this fungus.

In all the other previous cases, amphotericin B, either conventional or liposomal was used as an initial treatment with duration of therapy of 12 weeks [Table 1]. There is now some evidence that in amphotericin resistant cases, posaconazole is an effective drug and at least 60% of the amphotericin resistant cases can be salvaged by posaconazole therapy.[21] Whatever be the antifungal therapy, the role of source removal in the successful management of these patients cannot be overemphasized. In our case also, quick removal of the CAPD catheter as well as laparotomy and drainage of the intra-abdominal abscesses were helpful in the successful outcome.

The outcome of zygomycetes peritonitis is very dismal, with 11 of the 16 cases succumbing to the infection, while none of the surviving patient was able to go back on peritoneal dialysis. Our case is probably first from India documenting a successful outcome with the help of surgery and conventional amphotericin B.

Thus, a high index of suspicion in non-resolving peritonitis is required for diagnosing zygomyceteal peritonitis. If culture negative peritonitis gets complicated, we may need to suspect other unusual causes of peritonitis like an invasive fungal infection or mycobacterial infection. Early documentation of fungi with the help of peritoneal dialysis effluent culture or peritoneal biopsy, rapid institution of antifungal therapy and a low threshold for surgery are key parameters for a successful outcome of these patients.


Notes

Source of Support: Nil

Conflict of Interest: None declared.

References
1. Chugh KS,Jha V. Differences in the care of ESRD patients worldwide: Required resources and future outlookKidney Int SupplYear: 199550S7138544436
2. Li PK,Szeto CC,Piraino B,Bernardini J,Figueiredo AE,Gupta A,et al. Peritoneal dialysis-related infections recommendations: 2010 updatePerit Dial IntYear: 20103039342320628102
3. Bibashi E,Memmos D,Kokolina E,Tsakiris D,Sofianou D,Papadimitriou M. Fungal peritonitis complicating peritoneal dialysis during an 11-year period: Report of 46 casesClin Infect DisYear: 2003369273112652395
4. Sedlacek M,Cotter JG,Suriawinata AA,Kaneko TM,Zuckerman RA,Parsonnet J,et al. Mucormycosis peritonitis: More than 2 years of disease-free follow-up after posaconazole salvage therapy after failure of liposomal amphotericin BAm J Kidney DisYear: 200851302618215708
5. Nayak S,Satish R,Gokulnath,Savio J,Rajalakshmi T. Peritoneal mucormycosis in a patient on CAPDPerit Dial IntYear: 200727216717299165
6. Ram R,Swarnalatha G,Prasad N,Dakshinamurty KV. Exit site infection due to Zygomycosis resulting in abdominal wall necrosis in a continuous ambulatory peritoneal dialysis patientNephrol Dial TransplantYear: 200722266716998224
7. Matuszkiewicz-Rowinska J. Update on fungal peritonitis and its treatmentPerit Dial IntYear: 200929Suppl 2S161519270208
8. Khanna R,Oreopoulos DG,Vas S,McCready W,Dombros N. Fungal peritonitis in patients undergoing chronic intermittent or continuous ambulatory peritoneal dialysisProc Eur Dial Transplant AssocYear: 19801729167243781
9. Nakamura M,Weil WB Jr,Kaufman DB. Fatal fungal peritonitis in an adolescent on continuous ambulatory peritoneal dialysis: Association with deferoxaminePediatr NephrolYear: 198938022702092
10. Polo JR,Luño J,Menarguez C,Gallego E,Robles R,Hernandez P. Peritoneal mucormycosis in a patient receiving continuous ambulatory peritoneal dialysisAm J Kidney DisYear: 19891323792919604
11. Branton MH,Johnson SC,Brooke JD,Hasbargen JA. Peritonitis due to Rhizopus in a patient undergoing continuous ambulatory peritoneal dialysisRev Infect DisYear: 19911319212017628
12. Fergie JE,Fitzwater DS,Einstein P,Leggiadro RJ. Mucor peritonitis associated with acute peritoneal dialysisPediatr Infect Dis JYear: 1992114985001608691
13. Adam RD,Hunter G,DiTomasso J,Comerci G Jr. Mucormycosis: Emerging prominence of cutaneous infectionsClin Infect DisYear: 19941967767948560
14. Mariano F,Rossano C,Goia F,Cottino R,Dogliani N,Cavalli PL. Systemic mucormycosis in dialysis: Computed tomography picture and histologic lesionsMinerva Urol NefrolYear: 1996485148848770
15. Khan ZU,Chugh TD. Invasive fungal infections in Kuwait: A retrospective studyIndian J Chest Dis Allied SciYear: 2000422798715597675
16. del Río Pérez O,Santín Cerezales M,Mañós M,Rufí Rigau G,Gudiol Munté F. Mucormycosis: A classical infection with a high mortality rate. Report of 5 casesRev Clin EspYear: 2001201184711447902
17. Nannini EC,Paphitou NI,Ostrosky-Zeichner L. Peritonitis due to Aspergillus and zygomycetes in patients undergoing peritoneal dialysis: Report of 2 cases and review of the literatureDiagn Microbiol Infect DisYear: 200346495412742319
18. Serna JH,Wanger A,Dosekun AK. Successful treatment of mucormycosis peritonitis with liposomal amphotericin B in a patient on long-term peritoneal dialysisAm J Kidney DisYear: 200342E14712955706
19. Monecke S,Hochauf K,Gottschlich B,Ehricht R. A case of peritonitis caused by Rhizopus microsporusMycosesYear: 2006491394216466449
20. Pimentel JD,Dreyer G,Lum GD. Peritonitis due to Cunninghamella bertholletiae in a patient undergoing continuous ambulatory peritoneal dialysisJ Med MicrobiolYear: 200655115816388039
21. Rogers TR. Treatment of zygomycosis: Current and new optionsJ Antimicrob ChemotherYear: 200861Suppl 1i354018063603

Figures

[Figure ID: F1]
Figure 1 

(a) Intra-operative photograph showing dense adhesions between bowel loops and peritoneum. (b) Peritoneal biopsy showing necrosis and broad aseptate hyphae (arrow)



Tables
[TableWrap ID: T1] Table 1 

Clinical profile and outcome of published cases of zygomycetes peritonitis




Article Categories:
  • Case Report

Keywords: Continuous ambulatory peritoneal diagnosis, laparotomy, peritonitis, zygomycetes.

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