A case of rare, fungal peritonitis caused by Histoplasma capsulatum in a patient on CAPD

Acute Peritoneal Histoplasmosis Mimicking Ovarian Cancer and Review of the Literature on Histoplasma Peritonitis

Peritoneal histoplasmosis is a rare entity with few cases reported in the literature. We present a case of isolated acute peritoneal histoplasmosis that mimicked an advanced ovarian malignancy in a patient undergoing antitumor necrosis factor therapy for rheumatoid arthritis. We also reviewed the literature on Histoplasma peritonitis.

Continuous ambulatory peritoneal dialysis-associated Histoplasma capsulatum peritonitis: a case report and literature review

Background

Fungal peritonitis (FP) is a rare complication of peritoneal dialysis. We herein describe the second case in Asia of Histoplasma capsulatum peritonitis associated with continuous ambulatory peritoneal dialysis (CAPD).

Case presentation

An 85-year-old woman with end-stage renal disease (ESRD) who had been on CAPD for 3 years and who had a history of 3 prior episodes of peritonitis presented with intermittent abdominal pain for 2 weeks and high-grade fever for 3 days. Elevated white blood cell (WBC) count and rare small oval budding yeasts were found in her peritoneal dialysis (PD) fluid. From this fluid, a white mold colony was observed macroscopically after 7 days of incubation, and numerous large, round with rough-walled tuberculate macroconidia along with small smooth-walled microconidia were observed microscopically upon tease slide preparation, which is consistent with H. capsulatum. The peritoneal dialysis (PD) catheter was then removed, and it also grew H. capsulatum after 20 days of incubation. The patient was switched from CAPD to hemodialysis. The patient was successfully treated with intravenous amphotericin B deoxycholate (AmBD) for 2 weeks, followed by oral itraconazole for 6 months with satisfactory result. The patient remains on hemodialysis and continues to be clinically stable.

Conclusion

H. capsulatum peritonitis is an extremely rare condition that is associated with high morbidity and mortality. Demonstration of small yeasts upon staining of PD fluid, and isolation of slow growing mold in the culture of clinical specimen should provide important clues for diagnosis of H. capsulatum peritonitis. Prompt removal of the PD catheter and empirical treatment with amphotericin B or itraconazole is recommended until the culture results are known.

Peritoneal histoplasmosis. Case report

Introduction: Histoplasmosis is an opportu­nistic granulomatous fungal infection. Peritoneal histoplasmosis (PH) is a rare form of dissem­inated histoplasmosis (DH).Case description: A 44-year-old male pa­tient with history of HIV infection, systemic lupus erythematosus with lupus nephritis, and chronic kidney disease on peritoneal dialysis, presented with recurrent ascites without clear etiology in the serial study of ascitic fluid. Con­trast computed tomography of the abdomen showed a nonspecific peritoneal nodule, for which laparoscopy and biopsy were performed, identifying Histoplasma capsulatum infection. The subject received 15 days of in-hospital treatment with amphotericin B deoxycholate with good evolution, no recurrence of ascites, and indefinite outpatient management with itraconazole.Discussion: The first case of PH was described in 1970 but this is the first case reported in Co­lombia. Most cases of PH have been associated with peritoneal dialysis. Its diagnosis is based on the study of ascitic fluid and its treatment follows the guidelines of other forms DH.Conclusions: PH is a rare entity that requires high clinical suspicion, especially in immuno­compromised patients.

Histoplasma Peritonitis: An Extremely Rare Complication of Peritoneal Dialysis

Bacterial peritonitis is a common complication of peritoneal dialysis, but fungal peritonitis is unusual and is mostly due to Candida species. Peritonitis due to Histoplasma capsulatum is rare and we report one such case. A 63-year-old female presented with progressively worsening abdominal pain, fever, and altered mental status. She had end-stage renal disease and had been on peritoneal dialysis for 4 years. She had abdominal tenderness without rebound or guarding. Laboratory studies and CT of abdomen were significant for leukocytosis and peritoneal membrane thickening, respectively. Peritoneal dialysis fluid study was consistent with peritonitis and culture of the fluid grew Histoplasma capsulatum. Treatment recommendations include removal of catheter and initiation of antifungal therapy. With the availability of newer antifungals, medical management without removal of PD catheter is possible, but at the same time if there is no response to treatment within a week, PD catheter should be removed promptly.

Could Histoplasma capsulatum Be Related to Healthcare-Associated Infections?

Healthcare-associated infections (HAI) are described in diverse settings. The main etiologic agents of HAI are bacteria (85%) and fungi (13%). Some factors increase the risk for HAI, particularly the use of medical devices; patients with severe cuts, wounds, and burns; stays in the intensive care unit, surgery, and hospital reconstruction works. Several fungal HAI are caused by Candida spp., usually from an endogenous source; however, cross-transmission via the hands of healthcare workers or contaminated devices can occur. Although other medically important fungi, such as Blastomyces dermatitidis, Paracoccidioides brasiliensis, and Histoplasma capsulatum, have never been considered nosocomial pathogens, there are some factors that point out the pros and cons for this possibility. Among these fungi, H. capsulatum infection has been linked to different medical devices and surgery implants. The filamentous form of H. capsulatum may be present in hospital settings, as this fungus adapts to different types of climates and has great dispersion ability. Although conventional pathogen identification techniques have never identified H. capsulatum in the hospital environment, molecular biology procedures could be useful in this setting. More research on H. capsulatum as a HAI etiologic agent is needed, since it causes a severe and often fatal disease in immunocompromised patients.

Peritonitis caused by Blastomyces dermatitidis in a kidney transplant recipient: case report and literature review

Blastomyces dermatitidis is a dimorphic fungus endemic to the midwestern, south-central, and southeastern United States known to cause disseminated infection in immunocompromised individuals. We report a case of B. dermatitidis peritonitis in a renal allograft recipient with new-onset ascites and cytomegalovirus encephalitis. Peritoneal blastomycosis is a rare clinical entity and, to our knowledge, this patient represents the first known case of peritoneal blastomycosis in a solid organ transplant recipient. We review the clinical characteristics of B. dermatitidis peritonitis as well as the literature on fungal peritonitis with emphasis on dimorphic fungal pathogens. Clinical features suggestive of fungal peritonitis include new-onset ascites, abdominal pain, and fevers, especially with antecedent or concomitant pneumonia. A high index of clinical suspicion, along with the use of culture and non-culture diagnostics, is needed for early diagnosis and prompt initiation of therapy.