Peritonitis due to Cunninghamella bertholletiae in a patient undergoing continuous ambulatory peritoneal dialysis

Abstract

Peritoneal dialysis-associated peritonitis due to fungi of the class Zygomycetes occurs very rarely. A case of fungal continuous ambulatory peritoneal dialysis peritonitis due to Cunninghamella bertholletiae is reported in a 39-year-old Aboriginal woman with end-stage renal failure and diabetes mellitus. This isolate was found to be resistant in vitro to amphotericin B, 5-fluorocytosine, fluconazole, itraconazole, ketoconazole and voriconazole. However, this patient was successfully treated with voriconazole and removal of the Tenckhoff dialysis catheter. Zygomycoses are an emerging threat among immunocompromised patients, including those with chronic renal failure. Zygomycosis due to C. bertholletiae is frequently fatal and is often non-responsive to systemic antifungal therapy. This is believed to be the first reported case of C. bertholletiae causing peritonitis in humans and one of the minority of cases involving this organism with a successful outcome.

Mucormycosis Caused by Unusual Mucormycetes, Non-Rhizopus, -Mucor, and -Lichtheimia Species

“…Only one case of C. bertholletiae peritonitis has been reported. This infection occurred secondary to use of a Tenckhoff catheter for continuous ambulatory peritoneal dialysis (262). The patient, a 39-year-old aboriginal diabetic woman with end-stage renal failure, recovered after catheter removal (262).…”

“…Percutaneous inoculation of C. bertholletiae, although less common, has been described from the inpatient (218,251), outpatient (262), and community (122,267) settings, following pleural taps (218), peritoneal dialysis (262), use of blood glucose self-monitoring equipment (122), and insulin injections (267). Several adhesive products used in hospitals have been linked with the development of Mucormycetes wound infections (40,279,280), including C. bertholletiae infections (218).…”

“…The species appears as branched sporangiophores terminating at a swollen, terminal vesicle with spherical, ovoidal, or ellipsoidal sporangioles (Fig. 3) (34,181,262,279,283).…”

False-Negative Culture Results with Fungal Isolates from Peritoneal Dialysis Fluid

“…Recently, newly reported causes of fungal peritonitis associated with continuous ambulatory peritoneal dialysis were described both in this journal and in another (6,7). These episodes threatened to go undetected due to false-negative culture results in the initial investigations.…”

“…It is likely that due to the filamentous nature of these fungi (Curvularia inaequalis [6] and Cunninghamella bertholletiae [7]), the clumps of mycelium did not rapidly travel down into the neck of the bottle when inverted. As such, it is also likely that the reach of the needle was exceeded and no hyphae were drawn out, yielding negative microscopy results.…”