Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
Year
: 2021  |  Volume : 32  |  Issue : 1  |  Page : 245--248

Candida tropicalis in Peritoneal Dialysis-related Peritonitis Diagnosed by Matrix-assisted Laser Desorption/ionization Time-of-flight Mass Spectrometry


María Guadalupe Ramirez Ramirez, Héctor Raúl Ibarra Sifuentes, Sergio Raúl Alvizures Solares, Giovanna Yazmin Arteaga Muller, Jesús Cruz Valdez 
 Department of Internal Medicine; Department of Nephrology Service, University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México

Correspondence Address:
Héctor Raúl Ibarra Sifuentes
Department of Internal Medicine, University Hospital, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León
México

Abstract

Fungal peritonitis (FP) is a rare complication of peritoneal dialysis (PD). Candida tropicalis infections are rarely reported in literature. The authors present the first case of FP with peritoneal abscess due to C. tropicalis in a 22-year-old woman admitted to our hospital with septic shock. Abdominal tomography demonstrated an abscess in peritoneal space and intraluminal bubble appearance in femoral venous and arterial circulation. PD fluid specimens and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) analysis revealed fungus growth of C. tropicalis. Fluconazole therapy was administered accompanied by catheter removal and mechanical ventilation with vasopressor support. The patient recovered after 23 days of hospitalization and was discharged. FP represents high mobility and mortality unless infection source control and appropriate antimicrobial therapy are implemented accompanied by PD catheter removal. The use of MALDI-TOF MS for PD-related peritonitis pathogen identification can promote early identification and appropriate antibiotic therapy, especially in C. tropicalis infection.



How to cite this article:
Ramirez Ramirez MG, Ibarra Sifuentes HR, Alvizures Solares SR, Arteaga Muller GY, Valdez JC. Candida tropicalis in Peritoneal Dialysis-related Peritonitis Diagnosed by Matrix-assisted Laser Desorption/ionization Time-of-flight Mass Spectrometry.Saudi J Kidney Dis Transpl 2021;32:245-248


How to cite this URL:
Ramirez Ramirez MG, Ibarra Sifuentes HR, Alvizures Solares SR, Arteaga Muller GY, Valdez JC. Candida tropicalis in Peritoneal Dialysis-related Peritonitis Diagnosed by Matrix-assisted Laser Desorption/ionization Time-of-flight Mass Spectrometry. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2021 Sep 21 ];32:245-248
Available from: https://www.sjkdt.org/text.asp?2021/32/1/245/318533


Full Text



 Introduction



The burden of chronic kidney disease is increasing worldwide, so is the use of the renal replacement therapy, such as peritoneal dialysis (PD), especially in low-income countries.

The use of PD therapy implies a significant mobility and mortality risk, such as PD-related peritonitis, which is a common and serious complication. The recommended peritonitis rate in an established program should be <0.5 episodes per year.[1] Each PD unit should document its own pattern of infection, causative organisms with sensitivities, and adjust protocols according to its local conditions to set this goal. Fungal peritonitis (FP) is a feared complication with high rates of complications, hospitalization, catheter removal, transition to hemodialysis (HD), and death.[2],[3],[4]

 Case Report



Informed consent was obtained from the patient for the publication of this case report.

A 22-year-old woman was admitted to our hospital because of subtle altered consciousness. Her medical history was significant for end-stage renal disease secondary to type 1 diabetes mellitus, who started continuous ambulatory PD seven months prior to her admission with intermittent compliance. On clinical examination, she has reduced alertness, completely unaware, and unresponsive to external stimuli. The patient was hemodynamically unstable, her blood pressure was 60/40 mm Hg, heart rate was 118 beats/min, respiratory rate was 24 breaths/min, and body temperature was 38°C, with three points on qSOFA score. Bowel sounds were absent; periumbilical tenderness, defense, and rebound were present, but catheter exit site was unrevealing. Laboratory examinations revealed white blood cells of 20 cell/dL, hemoglobin was 9.9 g/dL, serum potassium was 4.7 mEq/L, blood urea nitrogen of 79 mg/dL, venous blood pH was 7.15, lactate 4.5 mmol/L, and bicarbonate was 9 mEq/L. Aggressive hemodynamic support was implemented with invasive mechanical ventilation and intravenous vasopressors. Peritoneal fluid analysis revealed a cell count of 3422 cells/μL with 51% of polymorphonuclear cells and 49% of lymphocytes. Abdominal computed tomography showed a hypodense mass with gas bubbles in peritoneal space and intra-luminal bubble appearance in femoral venous and arterial circulation [Figure 1]. This diagnostic procedure was immediately followed by percutaneous computed tomography-guided abscess drainage. Peritoneal liquid and abscess samples were collected for microbiological analysis, in which Candida tropicalis was identified, also were analyzed using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). Therefore, FP was diagnosed, the patient received intravenous fluconazole therapy and PD catheter removal with clinical improvement. After 23 days of hospital stay, the patient was discharged free of symptoms and in a good general condition referred for in-center HD therapy; also, arteriovenous fistula creation was performed. At six months of follow-up, the patient remains in good clinical condition and was enrolled on a transplant waiting list.{Figure 1}

 Discussion



Few data regarding FP are available in the literature, but compared to bacterial peritonitis, FP is rare entity; it represents 1%–15% of peritonitis episodes in PD patients.[4],[5],[6] Interestingly, FP is not documented in our country registries.[6],[7] FP is documented as the cause of death in 5%–53% of PD patients.[5],[6] FP is associated with complications such as abscess formation and prolong peritonitis duration in 50% of the cases.[2]

In most FP cases, Candida species are most frequent causative pathogen (70%–90%).[3],[6],[8] C. tropicalis is very rarely reported in 2.6%– 13% of FP cases in large series,[3],[5],[6],[9],[10] but it has been documented in an outbreak hospital peritonitis of five cases with high mortality rate. Nonetheless, there is a rising increase of non-albicans Candida spp. infection.[5]

Previous bacterial peritonitis episodes, longer PD therapy duration, prior antibiotics use, immunosuppression status, diabetes mellitus, malnutrition, and prolonged time on PD are common risk factors for FP.[3] Broad-spectrum antibiotics reduce the normal skin, gastrointestinal and urological flora leading into Candida overgrowth; thus, nystatin or azole prophylaxis has a beneficial impact when a patient receives antibiotics for other adequate reasons.[11]

The most common route of FP infection is touch contamination. Clinical manifestations are similar to bacterial peritonitis such as cloudy peritoneal fluid, abdominal pain, and fever,[7] while some authors have reported a lower rate of fever and abdominal pain on admission.[3]

Diagnosis criteria are similar to those used for bacterial peritonitis, which includes two clinical manifestations consistent with peritonitis, PD fluid white cell count >100/μL with >50% neutrophils and positive PD fluid culture.[1],[5] The literature describes that the mean cell count on fungal-related dialysis peritonitis is 1745 (427 SD), but patients who have a positive culture have a higher mean cell count such as 2676 (681 SD) cells.[10] Diagnosis and microbiological identification by molecular techniques has already been proven high efficiency, mainly due to faster and greater sensitivity. Correct identification and characterization of causative pathogens provides improvements in management of FP, which could represent a positive effect on patient survival related to FP. It has been demonstrated that MALDI-TOF MS diagnostic method identifies the causative pathogen earlier and leads to an average time saved of 64 h; also, using this technique, patients had a shorter hospital stay.[12] Candida species have only reported in one case of PD-related peritonitis using MALDI-TOF MS as an identification method.[12]

Imaging studies on PD-related peritonitis is performed for seeking complications such as loculated fluid collections with wall enhancement, mesenteric inflammatory change, thickening of the small bowel wall, or adhesions with their associated sequelae such as obstruction or ischemia; also, catheter-related problems such as tunnel or exit-site infection and hernias.[13] Computed tomography peritoneography is superior to abdominal computed tomography imaging in identifying patient complications.[13]

Abscess formation is a severe complication in FP, this complication is associated with intra-abdominal adhesions, sclerosis, and loss of peritoneal function due to irreversible injury to peritoneal membrane.[2] FP due to Candida parpsilosis infection has more complication rate than other Candida species and has been described as the most common pathogen.[2] Notwithstanding, C. tropicalis infection has not been associated with abscess formation or prolonged FP duration.[2],[10],[14]

Guidelines emphasize immediate catheter removal as treatment of choice accompanied with an appropriate antifungal agent which should be continued for at least two weeks after catheter removal.[1] Guidelines suggest the use of fluconazole for the treatment of Candida species, echinocandins for Aspergillus and non-albicans Candida species-related infection, and posaconazole for filamentous fungi. Derived by observational studies, urgent catheter removal improves patient outcomes and mortality.[1],[3],[4],[8] Empirical antifungal therapy is justified in patients with septic shock in community-acquired infections and patients with postoperative infections.[15] Amphotericin B, fluconazole, voriconazole, and caspofungin have been demonstrated as effective antifungal agents when C. tropicalis is identified in FP.[9]

In patients with shock and systemic signs of infection, most authorities recommend infection source control by draining all collections larger than 3 cm.[15] Urgent surgery for intra-abdominal abscess alone is still required in situations where percutaneous drainage is unlikely to provide adequate source control. Reinsertion of PD catheter should be performed 4–6 weeks after the FP episode resolution.[5] Around a third of patients could return to PD therapy in a median time of 15 weeks.[6]

Higher Charlson comorbidity index and PD fluid white blood cell count >3000/mm3 at presentation predicted death.[6]

 Conclusion



FP is a rare infectious related complication on PD patients. FP represents high mobility and mortality, unless infection source control and appropriate antimicrobial therapy are implemented accompanied by PD catheter removal. Using MALDI-TOF MS for PD-related peritonitis pathogen identification can promote early identification and appropriate antibiotic therapy, especially in C. tropicalis infection.

Conflict of interest: None declared.

References

1Li PK, Szeto CC, Piraino B, et al. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int 2016; 36:481-508.
2Chen KH, Chang CT, Yu CC, Huang JY, Yang CW, Hung CC. Candida parapsilosis peritonitis has more complications than other Candida peritonitis in peritoneal dialysis patients. Ren Fail 2006;28:241-6.
3Chavada R, Kok J, van Hal S, Chen SC. Seeking clarity within cloudy effluents: Differentiating fungal from bacterial peritonitis in peritoneal dialysis patients. PLoS One 2011;6:e28247.
4Basturk T, Koc Y, Unsal A, et al. Fungal peritonitis in peritoneal dialysis: A 10 year retrospective analysis in a single center. Eur Rev Med Pharmacol Sci 2012;16:1696-700.
5Prasad N, Gupta A. Fungal peritonitis in peritoneal dialysis patients. Perit Dial Int 2005;25:207-22.
6Nadeau-Fredette AC, Bargman JM. Characteristics and outcomes of fungal peritonitis in a modern North American cohort. Perit Dial Int 2015;35:78-84.
7Afrashtehfar CD, Mastache-Gutiérrez A, Afrashtehfar KI, Díaz-Casales LA, Solís-Bazaldúa M. Clinical aspects and microbiology of peritoneal dyalisis-related peritonitis. Rev Med Inst Mex Seguro Soc 2014; 52:84-9.
8Hu S, Tong R, Bo Y, Ming P, Yang H. Fungal peritonitis in peritoneal dialysis: 5-year review from a North China center. Infection 2019;47:35-43.
9Giacobino J, Montelli AC, Barretti P, et al. Fungal peritonitis in patients undergoing peritoneal dialysis (PD) in Brazil: Molecular identification, biofilm production and anti-fungal susceptibility of the agents. Med Mycol 2016;54:725-32.
10San Juan M P, Pérez J A, Barrientos A C. Clinical and microbiological aspects of peritonitis associated with peritoneal dialysis in adult patients with chronic renal failure in the Emergency Department. Rev Chilena Infectol 2018;35:225-32.
11Campbell D, Mudge DW, Craig JC, Johnson DW, Tong A, Strippoli GF. Antimicrobial agents for preventing peritonitis in peritoneal dialysis patients. Cochrane Database Syst Rev 2017;4:CD004679.
12Lin WH, Hwang JC, Tseng CC, et al. Matrix-assisted laser desorption ionization-time of flight mass spectrometry accelerates pathogen identification and may confer benefit in the outcome of peritoneal dialysis-related peritonitis. J Clin Microbiol 2016;54:1381-3.
13Scanziani R, Pozzi M, Pisano L, et al. Imaging work-up for peritoneal access care and peritoneal dialysis complications. Int J Artif Organs 2006;29:142-52.
14Unal A, Kocyigit I, Sipahioglu MH, Tokgoz B, Oymak O, Utas C. Fungal peritonitis in peritoneal dialysis: An analysis of 21 cases. Int Urol Nephrol 2011;43:211-3.
15Sartelli M, Catena F, Abu-Zidan FM, et al. Management of intra-abdominal infections: Recommendations by the WSES 2016 consensus conference. World J Emerg Surg 2017;12:22.