NDT Advance Access originally published online on February 13, 2006
Nephrology Dialysis Transplantation 2006 21(7):2036-2037; doi:10.1093/ndt/gfl040
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Fatal Candida famata peritonitis complicating sclerosing peritonitis in a peritoneal dialysis patient
Email: Ajay.Gupta{at}ncl.ac.ukSir,
Fungi are rare causes of secondary peritonitis [1]. Most of these are caused by Candida species although other yeasts and dimorphic fungi may be isolated in some cases. We recently came across one such case of sclerosing peritonitis with superimposed Candida famata infection.
A 35-year-old male with a failed renal transplant, on continuous ambulatory peritoneal dialysis (CAPD) since 1997, developed Staphylococcal peritonitis while resident in South Africa. This was successfully treated with a course of vancomycin. However, 6 weeks later, he again manifested with signs of CAPD peritonitis. Candida famata was isolated from the peritoneal fluid. A CT scan revealed a loculated fluid collection lying anteriorly within the abdomen, containing several pockets of gas as well as a moderately thick capsule suggestive of infected sclerosing peritonitis. The above findings were confirmed on laparotomy for removal of the tenckhoff catheter. The patient was started on intravenous fluconazole with intraperitoneal amphotericin, which was later converted to intravenous vericonazole. A relaparotomy was done to free the encased bowel. Further laparotomies were done to evacuate blood clots and lavage. The patient also received intraperitoneal tauroline washouts during this period. However, he failed to respond to therapy and subsequently died.
Sclerosing peritonitis is an unusual form of peritonitis. This disease was first described in 1974 following oral use of beta blockers, especially practolol [2,3]. In 1983 sclerosing peritonitis was first described in a CAPD patient [4]. Other causes include luteinized thecoma, chlorhexidine washout, keratinoconjunctivitis sicca and peritoneal sarcoidosis. Chronic intestinal obstruction with profound weight loss or abdominal mass is the most common presentation. Other manifestations include haemoperitoneum and peritonitis. Peritonitis has been reported to occur in 38% of cases, with fungal peritonitis in 7% [5]. The development of bacterial or fungal peritonitis may bring the disease to light earlier, as in our case. Most cases of fungal peritonitis are caused by Candida (50–85%) with the majority being caused by Candida albicans. Other yeasts implicated include Cryptococcus, Trichosporon and Rhodotorula species. Dimorphic fungi causing peritonitis include Aspergillus, Penicillium and Paecelomyces. Management strategies include prompt diagnosis and removal of the dialysis catheter with administration of systemic antifungals.
Candida famata is an uncommon yeast. Previously called Torulopsis famata and Debaryomyces hansenii, the yeast is found in many dairy products like cheese. It is an opportunistic pathogen that is commensal in the oral cavity. The fungus has been implicated in sporadic case reports as causing onychomycosis, systemic blastomycosis, extrinsic allergic alveolitis, systemic fungaemia and endopthalmitis. Candida famata has been very rarely isolated in the culture of peritoneal fluid in peritonitis. The first and only documented case report in existing literature was reported in 1994. The yeast is increasingly isolated from patients and was found in 1.45% of urinary tract infections and in about 1–2% of patients with fungaemia [6]. Recently we reported a case of mediastinitis with Candida famata [7].
Rigby and Hawley [5], while reporting the Australian experience, noted that in most patients in whom sclerosing peritonitis was complicated by peritonitis, bowel function did not recover and the patient usually died of ongoing sepsis. This was exactly our experience, in that all efforts at treatment failed and the patient eventually succumbed to his illness.
To conclude, sclerosing peritonitis complicated by fungal peritonitis is a serious complication. Newer strains of candida are being implicated. Candida famata is currently emerging as a significant pathogen in humans.
Conflict of interest statement. None declared.
Renal/liver transplant Unit Freeman Hospital Newcastle upon Tyne United Kingdom
References
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- Brown P, Baddeley H, Read AE, Davies JD, McGarry J. Sclerosing peritonitis, an unusual reaction to a beta-adrenergic-blocking drug (practolol). Lancet 1974; 2: 1477–1481[CrossRef][Web of Science][Medline]
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[Abstract/Free Full Text]
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