Clin Kidney J (2012) 5: 605–606 doi: 10.1093/ckj/sfs120
Images in Nephrology
(Section Editor: G. H. Neild) Paecilomyces puntonii fungal peritonitis Shilpa Reddy1, Anusha Rohit2, Anupma Jyoti Kindo1 and Georgi Abraham2 1
Sri Ramachandra Medical College and Research Institute, Chennai, India and 2The Madras Medical Mission, Chennai, India
Correspondence and offprint requests to: Anusha Rohit; E-mail: [email protected]
A 61-year-old hypertensive woman on continuous ambulatory peritoneal dialysis (CAPD) with a swan neck Tenckhoff catheter for the past 2 years undergoing four exchanges/day, and on anti-tuberculous treatment presented with poor drainage of the dialysate effluent for 5 days. At presentation, a cheesy material was seen in the catheter with cloudy effluent and poor inflow–outflow. The exit site and tunnel were normal. The dialysate fluid cell count was 300 cells/mm3 with neutrophils 36% and lymphocytes 64%. Fungal culture showed filamentous molds growth after 48 h. The catheter was removed and a peritoneal biopsy was done which showed mild focal fibrosis with chronic inflammation. She was switched over to hemodialysis and initiated on oral voriconazle 200 mg twice daily for 8 days. Fungal culture on Sabauraud’s agar showed slowgrowing spreading colonies brownish in color. Lactophenol Cotton Blue mount revealed conidiophores on simple bearing whorls of conidiogenous cells which were swollen. Chlamydospores were smooth walled and borne singly, identifying them as Paecilomyces puntonii (Figure 1). After 2 months, using a laparoscopic method, a Tenckhoff swan neck double cuff catheter was reimplanted as there were no adhesions. The patient was reinitiated on CAPD using 2 L exchanges of dineal four times a day. She
has a good ultrafiltration with a volume of 1200 mL/day and is doing well. The genus Paecilomyces may be distinguished from closely related Penicillium by having long, slender, divergent phialides and colonies that are never typically green. Incidence of fungal peritonitis in India may be found in as many as 24% of cases of peritonitis [1]. The risk factors for fungal peritonitis in peritoneal dialysis are prolonged usage of antibiotics, and previous bacterial peritonitis. Catheter removal immediately after fungi are identified by microscopy or culture is recommended [2]. Conflict of interest statement. None declared.
References 1. Ram R, Swarnalatha G, Neela P et al. Fungal Peritonitis in patients on Continuous ambulatory peritoneal dialysis: A single-centre experience in India. Nephron Clin Pract 2008; 110: c207–212 2. Philip KTL, Cheuk CS, Beth P et al. Peritoneal dialysis-related infections Recommendations: 2010 update. Perit Dial Int 2010; 30: 393–423 Received for publication: 4.7.12; Accepted in revised form: 30.7.12
© The Author 2012. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For permissions, please email: [email protected].
Downloaded from http://ckj.oxfordjournals.org/ at Grand Valley State University on May 6, 2015
Keywords: CAPD; paeciliomyces; voriconazole
606
Downloaded from http://ckj.oxfordjournals.org/ at Grand Valley State University on May 6, 2015
Fig. 1. (A) Chlamydospore and (B) Conidiophore. Microscopy depicting filamentous fungi Paecilomyces puntonii (lacto phenol cotton blue stain). The presence of whorl-like arrangement of conidiogenous cells and conidiophores borne singly are characteristic features.
S. Reddy et al.
Images in Nephrology
(Section Editor: G. H. Neild) Paecilomyces puntonii fungal peritonitis Shilpa Reddy1, Anusha Rohit2, Anupma Jyoti Kindo1 and Georgi Abraham2 1
Sri Ramachandra Medical College and Research Institute, Chennai, India and 2The Madras Medical Mission, Chennai, India
Correspondence and offprint requests to: Anusha Rohit; E-mail: [email protected]
A 61-year-old hypertensive woman on continuous ambulatory peritoneal dialysis (CAPD) with a swan neck Tenckhoff catheter for the past 2 years undergoing four exchanges/day, and on anti-tuberculous treatment presented with poor drainage of the dialysate effluent for 5 days. At presentation, a cheesy material was seen in the catheter with cloudy effluent and poor inflow–outflow. The exit site and tunnel were normal. The dialysate fluid cell count was 300 cells/mm3 with neutrophils 36% and lymphocytes 64%. Fungal culture showed filamentous molds growth after 48 h. The catheter was removed and a peritoneal biopsy was done which showed mild focal fibrosis with chronic inflammation. She was switched over to hemodialysis and initiated on oral voriconazle 200 mg twice daily for 8 days. Fungal culture on Sabauraud’s agar showed slowgrowing spreading colonies brownish in color. Lactophenol Cotton Blue mount revealed conidiophores on simple bearing whorls of conidiogenous cells which were swollen. Chlamydospores were smooth walled and borne singly, identifying them as Paecilomyces puntonii (Figure 1). After 2 months, using a laparoscopic method, a Tenckhoff swan neck double cuff catheter was reimplanted as there were no adhesions. The patient was reinitiated on CAPD using 2 L exchanges of dineal four times a day. She
has a good ultrafiltration with a volume of 1200 mL/day and is doing well. The genus Paecilomyces may be distinguished from closely related Penicillium by having long, slender, divergent phialides and colonies that are never typically green. Incidence of fungal peritonitis in India may be found in as many as 24% of cases of peritonitis [1]. The risk factors for fungal peritonitis in peritoneal dialysis are prolonged usage of antibiotics, and previous bacterial peritonitis. Catheter removal immediately after fungi are identified by microscopy or culture is recommended [2]. Conflict of interest statement. None declared.
References 1. Ram R, Swarnalatha G, Neela P et al. Fungal Peritonitis in patients on Continuous ambulatory peritoneal dialysis: A single-centre experience in India. Nephron Clin Pract 2008; 110: c207–212 2. Philip KTL, Cheuk CS, Beth P et al. Peritoneal dialysis-related infections Recommendations: 2010 update. Perit Dial Int 2010; 30: 393–423 Received for publication: 4.7.12; Accepted in revised form: 30.7.12
© The Author 2012. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For permissions, please email: [email protected].
Downloaded from http://ckj.oxfordjournals.org/ at Grand Valley State University on May 6, 2015
Keywords: CAPD; paeciliomyces; voriconazole
606
Downloaded from http://ckj.oxfordjournals.org/ at Grand Valley State University on May 6, 2015
Fig. 1. (A) Chlamydospore and (B) Conidiophore. Microscopy depicting filamentous fungi Paecilomyces puntonii (lacto phenol cotton blue stain). The presence of whorl-like arrangement of conidiogenous cells and conidiophores borne singly are characteristic features.
S. Reddy et al.
