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   Abstract
  Introduction
  Case Report
  Discussion
  Conclusion
  Acknowledgements
   References
   Article Figures

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  Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 25  |  Issue : 3  |  Page : 177-179
 

Successful catheter reinsertion in a case of Paecilomyces varioti peritonitis in a patient on continuous ambulatory peritoneal dialysis


Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India

Date of Web Publication13-May-2015

Correspondence Address:
S B Raju
Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad - 500 082, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-4065.147377

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  Abstract 

Peritonitis is one of the most common and important complications in patients on continuous ambulatory peritoneal dialysis (CAPD). Fungal peritonitis isreported in 4-8% of peritonitis episodes. Fungal peritonitis due to Paecilomyces species is not common. We report a case of CAPD peritonitis due to P. varioti. We immediately removed the CAPD catheter and IV amphotericin was administered for 4 weeks along with temporary hemodialytic support followed by successful catheter reinsertion.


Keywords: Amphotericin B, continuous ambulatory peritoneal dialysis peritonitis, fungal peritonitis, Paecilomyces varioti


How to cite this article:
Mandarapu S B, Mukku K K, Raju S B, Chandragiri S. Successful catheter reinsertion in a case of Paecilomyces varioti peritonitis in a patient on continuous ambulatory peritoneal dialysis. Indian J Nephrol 2015;25:177-9

How to cite this URL:
Mandarapu S B, Mukku K K, Raju S B, Chandragiri S. Successful catheter reinsertion in a case of Paecilomyces varioti peritonitis in a patient on continuous ambulatory peritoneal dialysis. Indian J Nephrol [serial online] 2015 [cited 2020 Apr 7];25:177-9. Available from: http://www.indianjnephrol.org/text.asp?2015/25/3/177/147377



  Introduction Top


Peritonitis is one of the most common factors responsible for morbidity and mortality in patients on continuous ambulatory peritoneal dialysis (CAPD). Both bacteria and fungi are known to cause peritonitis. Approximately 4-8% of peritonitis episodes have a fungal etiology, [1] Candida species accounting for 75%. [2] The reported incidence of mortality in bacterial peritonitis is approximately 0.6-3% and that in fungal peritonitis is 12-44%. [3] So, it is imperative that fungal peritonitis is diagnosed rapidly and appropriate treatment given so that the survival rates are improved.

Fungal peritonitis due to Paecilomyces species is not common. Very few case reports have been published worldwide. [4] Paecilomyces species are saprophytic fungi and are uncommon pathogens that can produce serious infections in immunocompromised patients and occasionally in immunocompetent hosts. [5] Reddy et al. reported a case of fungal peritonitis caused by Paecilomyces puntonii from India. [6] We report a case of fungal peritonitis caused by Paecilomyces varioti, which is not reported from India till date to the best of our knowledge.


  Case Report Top


A 51-year-old man was on CAPD had 2 episodes of culture negatibe peritonitis over the period of 2 years. First episode 2 months after the initiation of CAPD was treated with empirical antibiotics (vancomycin and amikacin) by intraperitoneal route; second episode 6 months prior to current admission and was treated with the same antibiotics. He again presented with complaints of diffuse abdominal pain and high grade fever with cloudy PD effluent. He also complained of diarrhea. On evaluation, his PD effluent cell count was 3000 cells/mm 3 with 80% polymorphs, Gram stain and AFB stain were negative, aerobic cultures did not grow any organism. He was again started on intraperitoneal amikacin and vancomycin. His PD effluent cell counts did not improve after 48 h of therapy. Fungal cultures by Sabouraud dextrose agar medium had grown filamentous fungi after 48 hours and microscopically it showed chains of single celled phialoconidia produced in basipetal succession from a phialide. phialides are swollen at their bases, gradually tapering towards their apices and formed a brush - like penicillus confirming the diagnosis of P. varioti [Figure 1]. Accordingly CAPD catheter was removed, he was initiated on hemodialysis mode Amphotericin B was started at 1 mg/kg/day. He was treated for a period of 4 weeks with a cumulative dose of 1.5 g of Amphotericin. CAPD catheter reinsertion was done successfully, he is currently on PD and is doing well.
Figure 1: Microscopic morphology of Paecilomyces varioti showing chains of single celled phialoconidia produced in basipetal succession from a phialide. phialides are swollen at their bases, gradually tapering towards their apices and may form a brush - like penicillus

Click here to view



  Discussion Top


In recent years, unusual and "nonpathogenic" fungi like Paecilomyces have been increasingly reported as etiologic agents of fungal peritonitis. These organisms have been considered to be nonpathogenic and troublesome laboratory contaminants. Paecilomyces are common saprophytic fungi found in soil, silage, and water. They are not usually associated with human infection. However, some species such as P. varioti, P. marquandii and P. lilacinus are emerging as causative agents of hyalohyphomycosis in the immunocompromised host. [7] P. varioti have been reported to cause pyelonephritis, [8] endophthalmitis, [9],[10] hairy-cell leukemia, [11] cerebrospinal shunt infection, [12] and prosthetic valve endocarditis. [13],[14]

The most important risk factors for fungal peritonitis are prolonged use of antibiotics and previous bacterial peritonitis episodes. A study by Goldie et al. reported that 65% of fungal peritonitis patients had received broad-spectrum antibiotics within the preceding month, 74% within 3 months, and 87% within 6 months. [15] Our patient presented with fungal peritonitis 6 months after empirical antibiotic therapy for suspected bacterial peritonitis. He also had two episodes of suspected bacterial peritonitis.

Filamentous fungi rarely contaminate the catheter via intraluminal route and cause peritoneal infection. P. varioti has been isolated from unused dialysate bags. [3] Several case series reported increased dialysate eosinophils. [16],[17] In other reported cases as well as in our patient, no eosinophilia was found in the dialysate. The treatment of fungal peritonitis is immediate catheter removal with temporary hemodialysis. The conventional antifungal regimens include fluconazole, Amphotericin B, and flucytosine alone or in combination, based on fungal sensitivities. P. varioti is usually very sensitive to Amphotericin B. [7] We used intravenous Amphotericin B for our patient who responded dramatically with cumulative dose of 1.5 g.


  Conclusion Top


Paecilomyces varioti is relatively a rare cause of peritonitis in patients on CAPD. Early diagnosis and prompt removal of the catheter can save patients life. It can be easily treated with common antifungal agents like Amphotericin B which can facilitate catheter reinsertion.


  Acknowledgements Top


We would like to thank Dr. P Uma Bala, Associate professor of Microbiology for having given microscopic picture of P. varioti.

 
  References Top

1.
Rubin J, Kirchner K, Walsh D, Green M, Bower J. Fungal peritonitis during continuous ambulatory peritoneal dialysis: A report of 17 cases. Am J Kidney Dis 1987;10:361-8.  Back to cited text no. 1
    
2.
Marzec A, Heron LG, Pritchard RC, Butcher RH, Powell HR, Disney AP, et al. Paecilomyces variotii in peritoneal dialysate. J Clin Microbiol 1993;31:2392-5.  Back to cited text no. 2
    
3.
Swartz RD. Chronic peritoneal dialysis: Mechanical and infectious complications. Nephron 1985;40:29-37.  Back to cited text no. 3
    
4.
Chan TH, Koehler A, Li PK. Paecilomyces varioti peritonitis in patients on continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1996;27:138-42.  Back to cited text no. 4
    
5.
Pastor FJ, Guarro J. Clinical manifestations, treatment and outcome of Paecilomyces lilacinus infections. Clin Microbiol Infect 2006;12:948-60.  Back to cited text no. 5
    
6.
Reddy S, Rohit A, Kindo AJ, Abraham G. Paecilomyces puntonii fungal peritonitis. Clin Kidney J 2012;5:605-6.  Back to cited text no. 6
    
7.
Kovac D, Lindic J, Lejko-Zupanc T, Bren AF, Knap B, Lesnik M, et al. Treatment of severe Paecilomyces varioti peritonitis in a patient on continuous ambulatory peritoneal dialysis. Nephrol Dial Transplant 1998;13:2943-6.  Back to cited text no. 7
    
8.
Sherwood JA, Dansky AS. Paecilomyces pyelonephritis complicating nephrolithiasis and review of Paecilomyces infections. J Urol 1983;130:526-8.  Back to cited text no. 8
    
9.
Levin PS, Beebe WE, Abbott RL. Successful treatment of Paecilomyces lilacinus endophthalmitis following cataract extraction with intraocular lens implantation. Ophthalmic Surg 1987;18:217-9.  Back to cited text no. 9
    
10.
Rodrigues MM, MacLeod D. Exogenous fungal endophthalmitis caused by Paecilomyces. Am J Ophthalmol 1975;79:687-90.  Back to cited text no. 10
    
11.
Dharmasena FM, Davies GS, Catovsky D. Paecilomyces varioti pneumonia complicating hairy cell leukaemia. Br Med J (Clin Res Ed) 1985;290:967-8.  Back to cited text no. 11
    
12.
Fagerburg R, Suh B, Buckley HR, Lorber B, Karian J. Cerebrospinal fluid shunt colonization and obstruction by Paecilomyces variotii. Case report. J Neurosurg 1981;54:257-60.  Back to cited text no. 12
    
13.
McClellan JR, Hamilton JD, Alexander JA, Wolfe WG, Reed JB. Paecilomyces varioti endocarditis on a prosthetic aortic valve. J Thorac Cardiovasc Surg 1976;71:472-5.  Back to cited text no. 13
    
14.
Haldane EV, MacDonald JL, Gittens WO, Yuce K, van Rooyen CE. Prosthetic valvular endocarditis due to the fungus Paecilomyces. Can Med Assoc J 1974;111:963-5, 968.  Back to cited text no. 14
    
15.
Goldie SJ, Kiernan-Tridle L, Torres C, Gorban-Brennan N, Dunne D, Kliger AS, et al. Fungal peritonitis in a large chronic peritoneal dialysis population: A report of 55 episodes. Am J Kidney Dis 1996;28:86-91.  Back to cited text no. 15
    
16.
Nankivell BJ, Pacey D, Gordon DL. Peritoneal eosinophilia associated with Paecilomyces variotii infection in continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1991;18:603-5.  Back to cited text no. 16
    
17.
Eisinger RP, Weinstein MP. A bold mold? Paecilomyces variotii peritonitis during continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1991;18:606-8.  Back to cited text no. 17
    


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