HDCN Ask the Professor:
Refractory Candida peritonitis
Question:
I have a question about the management of C. tropicalis
peritonitis with persistent production of a sterile peritoneal
exudate. One such patient responded to systemic amphotericin therapy
within several weeks of its institution symptomatically, but continued
to produce a peritoneal exudate that was yellow in color, protein
rich, and filled with a large number of mononuclear cells. All
cultures were negative but one could see branching hyphae on KOH
stain. We drained the fluid (1.5 liters at a time) intermittantly and
had catheters draining about 250-500 ml of the fluid a day with the
same characteristics as before. Subsquently we instilled fluconazole
into the peritoneal space without a change in the amount or character
of the fluid. Any experience with similar cases?
Robert
Safirstein, M.D. (University of Texas at Galveston)
John T. Daugirdas, M.D., (University of Illinois,
Chicago)
You really don't give details of how the patient was treated. Was the
original catheter ever removed? What were the details of the initial
treatment? Are you considering removing the catheter now? At the PD
meetings in Seattle there was an interesting discussion on the Quiz
the Experts panel on Rx of fungal peritonitis. You can order the
tape from Tree Farm
Communications.
Robert Safirstein, M.D. (University of Texas at
Galveston)
We removed the PD catheter immediately after
discovering that the peritonitis was caused by a fungus, and he has
been hemodialyzed via a PTFE graft ever since. He also had previous
bouts of bacterial peritonitis. The catheter drainage that I mention
was via temporary small lumen catheters inserted in his flanks to
drain the fluid. Because we were concerned about colonization even
these catheters were removed for a 6 week period on Amphotericin. The
fluid re-accumulated and we performed a diagnostic tap with a small
needle to culture and stain the fluid. This fluid was sterile but
showed hyphae on KOH stain. The fluid continued to collect and from
time to to time we drained it for a few days with similar small
catheters to tried to achieve apposition of the peritoneal membrane in
an effort to stop the drainage. All the while the patient clinically
was improving. We never were able to culture the fungus from his
fluid. I suspected that he continued to be infected and subsequently
we instilled fluconazole (the original organism was sensitive to this
drug) into the peritoneum during a period of drainage.
This question was referred to Beth M. Piraino, M.D.,
University of Pittsburgh.
Beth M. Piraino, M.D., (University of
Pittsburg)
I had a somewhat similar patient recently. The
patient developed Candida peritonitis, the catheter was removed and
he was given fluconazole orally. On CT scan he had multiple pockets
of fluid and the peripheral white blood cell count remained high. CT
guided tap of the fluid again grew Candida (different from the present
case). He was then treated with a total of 1000 mg of amphotericin
with very gradual resolution of the ascites. In view of the hyphae
still seen, this patient should be considered still infected and one
might consider treating with amphotericin.
(May, 1996)