Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
Year
: 2006  |  Volume : 17  |  Issue : 1  |  Page : 47--49

Rhodotorula Species Peritonitis in a Liver Transplant Recipient: A Case Report


Adel Alothman 
 Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia

Correspondence Address:
Adel Alothman
Department of Medicine (1443) King Abdulaziz Medical City P.O. Box 22490, Riyadh 11426
Saudi Arabia

Abstract

A 62-year-old man with a six months status post liver transplant due to hepatitis C infection, was admitted with ascites and pyrexia of unknown origin. Despite extensive investigations, his fever remained undiagnosed, so he was started empirically on anti tuberculous agents, ganciclovir and trimethoprim/sulfa. The liver function deteriorated and a liver biopsy showed evidence of allograft rejection for which the patient was started on systemic steroids. Later, yeast grew from the ascitic fluid, which was identified as Rhodotorula species. The draining peritoneal catheter was removed and the patient was started on Amphotericin B. The amphotericin was continued for 10 days during which the patient defervesced and repeat ascitic fluid culture became negative. In conclusion, Rhodotorula species infection is a rare form of infection in the immunocompromised host that is usually associated with indwelling catheter insertion. The infection responded to the removal of the indwelling catheter and amphotericin B treatment.



How to cite this article:
Alothman A. Rhodotorula Species Peritonitis in a Liver Transplant Recipient: A Case Report.Saudi J Kidney Dis Transpl 2006;17:47-49


How to cite this URL:
Alothman A. Rhodotorula Species Peritonitis in a Liver Transplant Recipient: A Case Report. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2020 Jul 13 ];17:47-49
Available from: http://www.sjkdt.org/text.asp?2006/17/1/47/32443


Full Text

 Introduction



Approximately two thirds of patients undergoing liver transplantation experience at least one episode of infection.[1] Liver trans­plant recipients have 20-42% incidence of fungal infections, which is higher than those with other solid organ transplantations. [1], [2]

Rhodotorula species are common airborne yeasts that can be isolated from human skin, lungs, urine and feces.[3],[4] The red yeast Rhodotorula has been an infrequent cause of infection in humans. [3],[4],[5],[6],[7] Rhodotorula species have emerged as human pathogens due to immunosuppression and foreign body tech­nology. [4],[5],[8],[9] The majority of these infections manifest as fungemia. [3],[4],[5],[6],[7],[9],[10],[11] However, there are other kinds of infections like meningitis 12 and peritonitis in patients undergoing continuous ambulatory peritoneal dialysis. [13]

Our case of Rhodotorula species peritonitis in a liver transplant patient may, to our knowledge, be the first case in medical literature.

 Case Report



A 62-year-old man, who was six months status post liver transplantation due to hepatitis C infection, was admitted as a case of pyrexia of unknown origin.

The cause of fever remained undiagnosed despite extensive investigative efforts. On the 3rd day of admission, the patient was started on anti tuberculous therapy for the presumptive diagnosis of tuberculosis (TB). These anti TB drugs were adjusted due to liver function. Because of lack of response, the patient was started on IV ganciclovir (GCV) for a presumptive diagnosis of CMV reactivation on the 8th day of admission.

Due to the development of pancytopenia, the hematology service was consulted on the 9th day of admission and a bone marrow biopsy showed no evidence of infectious or neoplastic pathology. On the10th day of admission, the pulmonary service was consulted to evaluate a persistent left lower lobe infiltrate. Bronchoscopy with broncho­alveolar lavage were performed. The lavage specimens were sent for several micro­biologic studies; however, all the results were negative. The patient was maintained on anti TB drugs and GCV as well as trime­thoprim/sulfa.

On 14th day of admission, the patient had a liver biopsy performed because of deterio­ration of the liver function, which showed evidence of allograft rejection. The patient was started subsequently on systemic steroids. Therapeutic paracentesis was done on that day and a peritoneal drain was left in place. The ascitic fluid specimen did not grow any organism.

On the 22nd day of admission, and because of intermittent high fever, a full septic work up was conducted including ascetic fluid culture that grew yeast, which was identified 48 hours later as Rhodotorula species. The peritoneal catheter was removed and the patient was started on amphotericin B (Ampho B) at a dose of 0.7 mg/kg/day. The regular Ampho B was changed to liposomal Ampho B three days later due to deteriorating renal function. The patient defervesced within 48 hours of therapy, improved clinically thereafter and the ascitic fluid cultures became negative. The total duration of antifungal treatment was 10 days.

Fever recurred on the 35th day of admi­ssion, and the patient started to deteriorate clinically with no obvious focus of infection or positive cultures. He was transferred to the Intensive Care Unit (ICU) where a lymph node biopsy was done and it showed evidence of lymphoproliferative disorder. The patient continued to deteriorate despite intensive therapeutic efforts and died on the 44th day of admission.

 Discussion



Members of the genus Rhodotorula, family Cryptococcaceae, are ubiquitous airborne fungi in the natural environment and in humans. Species of the genus Rhodotorula have been isolated from a number of sources including cheese, milk product, air, soil and water. [3]

Several authors have implicated the central venous catheterization as a major risk factor for Rhodotorula species fungemia. [3],[4],[5],[6],[7],[8],[9],[10],[11]

Our patient who is a liver transplant recipient required a peritoneal drain for his ascites. Most likely the peritoneal drain was the portal of entry for Rhodotorula species into the peritoneum causing infection. Removal of the peritoneal drain and a 10-day course of amphotericin B were sufficient to cure the patient from Rhodotorula species peritonitis. The fact that our patient received antifungal after removing the peritoneal catheter was based on his immuno­suppression status. Some authors recom­mended only the removal of the foreign body without administration of antifungal agents. [3],[4],[5],[6],[7],[8]

In conclusion, Rhodotorula species are one of the emerging human pathogens particularly in the context of immuno­suppression and instrumentation associated with solid organ transplantation, cancer and acquired immunodeficiency syndrome. The yeast is of low virulence and fatality rate. The removal of indwelling catheters is necessary to ensure an excellent outcome with or without administration of antifungal agents.

References

1Winston DJ, Emmanouilides C, Busuttil RW. Infections in liver transplant recipients. Clin Infect Dis 1995; 21:1077-91.
2Nicholson V, Johnson P. Infectious compli­cations in solid organ transplant recipients. Surg Clin North Am, 1994; 74:1223-45.
3Kiehn T, Gorey E, Brown AE, et al. Sepsis due to Rhodotarula related to Use of Indwelling Central Venous Catheter. Clin Inf Dis 1992; 14:841-6.
4Hsueh PR, Teng LJ, Hosw, Luh KT. Catheter related sepsis due to Rhodotarula glutinis. J Clin Microbial 2003; 41:857-9.
5Zaas AK, Boyce M, W. Schel-W et al. Risk of fungemia due to Rhodoturola and antifungal susceptibility testing of Rhodotarula isolates. J Clin Microbial 2003; 41:5233-5.
6Alliot-C, Desablens B, Garidi R, Tabuteall S. Opportunistic infection with Rhodotarula in cancer patients treated by chemotherapy: two case reports. Clin Oncol 2000; 12: 115-7.
7Braun D, Kaufmann C. Rhodotarula fungemia: a life threatening complications of indwelling central venous catheters. Myco­ses 1999; 35:305-8.
8Anatoliotaki M, Mantadakis E, Galanakis E, Samonis G. Rhodotarula a species fungemia: a threat to the immunocompro-mised host. Clin Lab 2003; 40:49-55.
9Kiraz N, Gulbas Z, Akgun Y. Rhodotarula fungemia due to use of indwelling venous catheter. Mycoses 2000; 43:209-10.
10Samonis G, Anatoliotaki M, Aposto-lakou H, etal. Transient fungemia due to Rhodotarula rubra in a cancer patient: case report and review of the literature. Infection 2001; 29; 173-6.
11Nareh Y, Friedman A, Merzbach D, Hashman N. Endocarditis caused by Rhodotarula successfully treated with 5­Fluorocytosine. Br Heart J 1975; 37:101-4.
12Lanzafame M, Dechecchi G; Parinello A, Trevengoli M, Cattelan AM. Rhodotarula glutinis related meningitis. J Clin Microbiol 2001; 39:410.
13Eisenberg ES, Alpert BE, Weiss RAY, Mittman N, Soeiro R. Rhodotarula rubra peritonitis in patients undergoing continuous ambulatory peritoneal dialysis. Am J Med 1983; 75:349-52.