| Abstract|| |
This is a case report of a 69 year-old African American female with end-stage renal disease secondary to hypertensive nephrosclerosis on chronic ambulatory peritoneal dialysis (CAPD) for five years. Her past was uneventful. She presented with symptoms and signs of acute peritonitis related to CAPD. There was initial response to antibiotics and culture was negative. The condition of the patient deteriorated despite the antibiotic. The peritoneal catheter was removed after five days of starting the antibiotic. The patient died at day seven of presentation due to septic shock and the culture eventually grew Candida lusitaniae, a rare agent of peritonitis in CAPD patients, which was resistant in vitro to amphotericin B.
Keywords: Candida, CAPD, Peritonitis, Renal failure.
|How to cite this article:|
Tarif N. Candida lusitaniae Peritonitis in a Chronic Ambulatory Peritoneal Dialysis Patient. Saudi J Kidney Dis Transpl 2004;15:170-3
|How to cite this URL:|
Tarif N. Candida lusitaniae Peritonitis in a Chronic Ambulatory Peritoneal Dialysis Patient. Saudi J Kidney Dis Transpl [serial online] 2004 [cited 2020 Jun 2];15:170-3. Available from: http://www.sjkdt.org/text.asp?2004/15/2/170/32901
| Introduction|| |
Fungal peritonitis (FP) has low incidence seen in only 2.8-14 /100 episodes of peritonitis, but usually results in significant morbidity in chronic ambulatory peritoneal dialysis (CAPD) patients. , The mortality was 22% in a recent review.  Commonly,
Candida albicans is the causative organism and rarely other species have been reported. ,, Candida lusitaniae (C. lusitaniae) is a rare fungal pathogen that causes disease in humans. Lusitaniae is named after a ship that was unsinkable; frequent presence of resistance to amphotericin B led to name this species accordingly. ,,,, A CAPD patient with C. lusitaniae peritonitis is described here.
| Case Report|| |
A 69 year-old African American female with end-stage renal disease secondary to hypertensive nephrosclerosis on CAPD for the last five years, was admitted to the University of Illinois-Chicago, USA with one day complaint of diarrhea, abdominal pain, nausea and vomiting. She was not febrile and noticed neither cloudy dialysate nor exit site discharge prior to her visit. No difficulty in inflow and outflow of dialysate was reported. Her current peritoneal dialysis regimen included 1.5% dextrose containing dialysis fluid instilled as three four-hourly exchanges during the day and one 4.25% exchange at night. She had hysterectomy and cholecystectomy in the past and developed Staphylococcus epidermidis peritonitis four months after the initiation of CAPD and Bacillus cereus peritonitis two years prior to this admission. On examination she had diffuse abdominal tenderness while the exit site was unremarkable. Her initial chemistry profile showed normal Amylase, negative serum ketones and mildly elevated liver enzymes; her peripheral white blood count (WBC) was 25,000 with 93% Neutrophils. Dialysate drainage was clear and the WBC count in it was 104 cells/mm 3 with neutrophils 84 %; with negative Gram stain for organisms. The patient was started on intraperitoneal vancomycin and gentamicin. 24 hours later, (xhemolytic streptococcus was isolated in the dialysate culture and the gentamicin was discontinued. The patient's symptoms improved and four days later was discharged with dialysate WBC count of only 4 cells/mm 3 . However, three days later she again developed abdominal pain and mild fever. The dialysate WBC count was 3000 cells/mm 3 with neutrophils 90%. A second dose of vancomycin was given and gentamicin was restarted. Her abdominal pain did not improve and an abdominal computerized tomography scan with contrast did not suggest intestinal pathology. Ceftazidime was added at 48 hours when repeat dialysate cell count showed an increase to 8000 cells/mm 3 ; gram stain was again negative. Since the patient's condition did not improve by 96 hours the peritoneal dialysis catheter was removed. The broad spectrum antibiotic coverage was initiated according to the advice of the infectious disease service at the hospital. The patient deteriorated suddenly and died on day seven of presentation due to septic shock. A day later the laboratory identified yeast species from the initial peritoneal fluid specimen confirmed to be C. lusitaniae, which was resistant to amphotericin B.
| Discussion|| |
FP is seldom spontaneous and mostly follows a prior course of antibiotics for peritonitis as was the case in our patient. , FP usually presents as worsening or non resolution of repeated episodes of peritonitis.  Most of the time, peritonitis due to fungal infection requires catheter removal as a part of management since antifungal agents alone may not be able to cure the infection. ,, Treatment of fungal peritonitis was successful in 76% of the cases when the catheter was removed compared to only 10 % if it was not.  Antifungal therapy is usually directed by the sensitivities of the organism in vitro. However, the initial antifungal agents can include 200 mg/day intraperitoneal fluconazole and 2.0 gram loading followed by 1.0 gram/day of oral Flucytosine C.  If there is no improvement by 4-7 days, catheter removal is recommended. Catheter reinsertion at the time of removal is recommended in only mild FP, since after severe FP only 47% will be able to return to CAPD. 
C. lusitaniae is a rare cause of FP; only three cases of peritonitis have been reported in the literature in CAPD patients. ,, In these three patients, the catheter was removed but only one survived. Our patient is the fourth described in the literature as far as we know.
C. lusitaniae is known for its resistance to amphotericin B as in our case. ,, In a recent review, 29.4% of non-CAPD patients with C. lusitaniae infection had resistance to amphotericin B. However, the patients survived in 20/28 (71.4%) cases; four had catheters removal (two central venous and one venoperitoneal shunt) and only three required combination therapy.  Moreover, despite the in vitro sensitivity of C. lusitaniae to amphotericin B in three patients, there was treatment failure.  Thus, in vitro sensitivity does not reflect the in vivo response of C. lusitaniae.
Prior antibiotic use has been identified as a risk factor for the development of FP and prophylactic use of nystatin was recommended to decrease the likelihood of FP in such patients. ,, A daily four times oral intake of 500,000 units of nystatin decreased the incidence to 1.9% compared to a 6.4% in controls in one study,  while another study failed to show similar beneficial effect. 
In conclusion, the approach to a CAPD peritonitis patient with C. lusitaniae should be early catheter removal along with amphotericin B or Fluconazole according to in vitro sensitivities. Prophylactic use of nystatin during a course of antibiotic therapy has not been conclusive in preventing fungal peritonitis.
| Acknowledgement|| |
Special thanks to Professor John T. Daugirdas, University of Illinois in Chicago-USA for his valuable advice in preparing this manuscript.
| References|| |
|1.||Keane WF, Bailie GR, Boeschoten E, etal.. Adult peritoneal -dialysis related peritonitis treatment recommendations : 2000 update. Perit Dial Int 2000;20:396-411. |
|2.||Lo WK, Chan TM, Lui SL, Li FK, Cheng IK. Fungal peritonitis: current status 1998. Perit Dial Int 1999;19[suppl 2]: S286-90. [PUBMED] [FULLTEXT]|
|3.||Bren A. Fungal peritonitis in patients on continuous ambulatory peritoneal dialysis. Eur J Clin Microbiol Infect Dis 1998; 17:839-43. [PUBMED] [FULLTEXT]|
|4.||Sanchez V, Vazquez JA, Barth-Jones D, Dembery L, Sobel JD, Zervos MJ Epidemiology of nosocomial acquisition of Candida lusitaniae. J Clin Microbial 1992; 30:3005-8. |
|5.||Hawkins JL, Baddour LM. Candida lusitaniae infections in the era of fluconazole availability. Clin Infect Dis 2003;36:e14-8 [PUBMED] [FULLTEXT]|
|6.||Garcia-Martos P, Diaz J, Castano M, Perez M, Marin P. Peritonitis caused by Candida lusitaniae in patient on continuous ambulatory peritoneal dialysis (CAPD). Clin Nephrol 1991;36:50. |
|7.||Pfaller MA, Messer SA, Hollis RJ. Strain delineation and antifungal susceptibilities of epidemiologically related and unrelated isolates of Candida lusitaniae. Diagn Microbiol Infect Dis 1994;20:127-33 [PUBMED] [FULLTEXT]|
|8.||Goldie SJ, Kierman-Tridle L, Torres C, et al. Fungal peritonitis in a large chronic peritoneal dialysis population: a report of 55 episodes. Am J Kidney Dis 1996;28:86-91. |
|9.||Cinar S. Nedret Koc A. Taskapan H. Dogukan A. Tokgoz B. Utas C. Case report. Candida lusitaniae peritonitis in a patient on continuous ambulatory peritoneal dialysis. Mycoses 2002;45(3-4):120-2. |
|10.||Anaissie EJ, Karyotakis NC, Hachem R, Dignani MC, Rex JH, Paetznick V. Correlation between in vitro and in vivo activity of antifungal agents against candida species. J Infect Dis 1994;170:384-9 [PUBMED] |
|11.||Zaruba K, Peters J, Jungbluth H. Successful prophylaxis for fungal peritonitis in patients on continuous ambulatory peritoneal dialysis: Six years' experience. Am J Kidney Dis 1991;17:43-6. |
|12.||Lo WK, Cheng IK. Who is going to benefit from nystatin prophylaxis for fungal peritonitis complicating CAPD? Perit Dial Int1999;19:185. |
|13.||Lo WK, Chan CY, Cheng SW, Poon JF, Chan DT, Cheng IK. A prospective randomized control study of oral nystatin prophylaxis for Candida peritonitis complicating continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1996;28:549-52. [PUBMED] |
|14.||Thodis E, Vas S, Bargman JM, Singhal M, Chu M, Oreopoulos DG. Nystatin prophylaxis: its inability to prevent fungal peritonitis in patients on continuous ambulatory peritoneal dialysis. Perit Dial Int 1998;18(6):583-9. |
Consultant Nephrologist, King Khalid University Hospital, P.O. Box 2925 (38), Riyadh 11461