Fungal Culture Positivity in Patients with Perforation Peritonitis

Pathophysiology and surgical outcomes of patients with fungal peritonitis from upper gastrointestinal tract perforation: a retrospective study

PURPOSE

To compare the pathophysiology and surgical outcomes of emergency surgery for upper gastrointestinal tract perforation with and without fungal peritonitis and identify the risk factors for fungal peritonitis.

METHODS

The subjects of this retrospective study were patients with upper gastrointestinal perforation and peritonitis who underwent emergency surgery at a single medical center in Japan. The patients were allocated to two groups according to the presence or absence of fungal peritonitis: group F and group N, respectively.

RESULTS

At the time of surgery, ascitic fluid culture or serum β-D glucan levels were available for 54 patients: 29 from group F and 25 from group N, respectively. The stomach was perforated in 14 patients (25.9%) and the duodenum was perforated in 40 patients (74.1%). Group F had a higher proportion of patients with low preoperative prognostic nutritional index scores (≤ 40) and C-reactive protein levels and a higher postoperative complication rate. The time to initiate food intake and the postoperative hospital stay were also significantly longer in group F. Multivariate analysis identified that the perforation site of the stomach was a risk factor for fungal peritonitis.

CONCLUSION

Patients with fungal peritonitis from upper gastrointestinal tract perforation had higher postoperative complication rates, delayed postoperative recovery, and a longer hospital stay. Gastric perforation was a risk factor for fungal peritonitis.

Superior Mesenteric Artery Syndrome as a Rare Cause of Postoperative Intractable Vomiting: A Case Report

BACKGROUND

Superior mesenteric artery syndrome is a very rare cause of proximal intestinal obstruction. The objective of this clinical case report is to highlight that this unusual condition can occur in the early postoperative period and medical management may completely cure the condition.

CLINICAL CASE

A middle-aged female who was being treated for pulmonary tuberculosis underwent exploratory laparotomy with limited ileal resection and a loop ileostomy for multiple ileal perforations. Postoperatively, she was restarted on anti-tubercular drugs (ATD) but developed a drug reaction, recurrent bilious vomiting, and jaundice and ATD had to be stopped. But her vomiting did not abate and she progressively developed septicemia. An abdominal CT scan diagnosed Wilkie's syndrome, and she was managed non-operatively by decubitus, parenteral nutrition, and nasojejunal tube feeding supplemented with prokinetics and antibiotics. But her sepsis did not resolve. Intraoperative histopathology suggested Candida infection, and she recovered only after systemic antifungal therapy.

DISCUSSION

Debilitation conditions like tuberculosis cause weight loss and loss of intra-abdominal fat pad, which is known to precipitate SMA syndrome. However, its presentation in the early post-operative period is rare. Symptoms may vary from non-specific abdominal fullness and weight loss to features of acute bowel obstruction. CECT of whole abdomen can help in confirming the diagnosis. SMA syndrome is often not considered in differential diagnosis and can delay treatment. Medical management is the mainstay treatment option, although surgery is reserved for cases, which fail medical treatment.

CONCLUSION

High suspicion is needed to diagnose SMA syndrome in the postoperative period, which precipitates with intractable bilious vomiting. Medical management may be curative. The precipitating factor for SMA syndrome should also be addressed to improve the overall patient outcome.

Gastric Candidiasis Leading to Perforation: An Unusual Presentation

Candidal infection of the gastrointestinal tract (GIT) is rare but has recently increased due to the increased number of immunocompromised patients, injudicious use of antibacterial agents, and prolonged use of antacid drugs in immunocompetent patients. The most frequent organ involved in GIT candidiasis is the esophagus, followed by the stomach, small intestine, and large intestine. The clinical spectrum of gastric candidiasis ranges from asymptomatic to gastric perforation and even shock. This case report presents a 58-year-old immunocompetent male patient diagnosed with Candida tropicalis-induced gastric perforation peritonitis.

Pharmacokinetics and Antifungal Activity of Echinocandins in Ascites Fluid of Critically Ill Patients

The pharmacokinetics and antifungal activity of the echinocandins anidulafungin (AFG), micafungin (MFG), and caspofungin (CAS) were assessed in ascites fluid and plasma of critically ill adults treated for suspected or proven invasive candidiasis. Ascites fluid was obtained from ascites drains or during paracentesis. The antifungal activity of the echinocandins in ascites fluid was assessed by incubation of Candida albicans and Candida glabrata at concentrations of 0.03 to 16.00 μg/ml. In addition, ascites fluid samples obtained from our study patients were inoculated with the same isolates and evaluated for fungal growth. These patient samples had to be spiked with echinocandins to restore the original concentrations because echinocandins had been lost during sterile filtration. In ascites fluid specimens of 29 patients, echinocandin concentrations were below the simultaneous plasma levels. Serial sampling in 20 patients revealed a slower rise and decline of echinocandin concentrations in ascites fluid than in plasma. Proliferation of C. albicans in ascites fluid was slower than in culture medium and growth of C. glabrata was lacking, even in the absence of antifungals. In CAS-spiked ascites fluid samples, fungal CFU counts moderately declined, whereas spiking with AFG or MFG had no relevant effect. In ascites fluid of our study patients, echinocandin concentrations achieved by therapeutic doses did not result in a consistent eradication of C. albicans or C. glabrata. Thus, therapeutic doses of AFG, MFG, or CAS may result in ascites fluid concentrations preventing relevant proliferation of C. albicans and C. glabrata, but do not warrant reliable eradication.

Concomitant fungal peritonitis and high ascitic amylase as a rare manifestation of gastric perforation

High ascitic amylase concentration has been reported to be a characteristic of pancreatic ascites. However, values greater than 2000 U/l can also be seen in intestinal perforation. Fungal peritonitis is a serious entity that could also be caused by hollow viscous perforation. Herein we report a 22-year-old woman with epigastric pain, imitating an acute pancreatitis, and abdominal distention. Laboratory and radiological investigations revealed a high ascitic Amylase level with secondary fungal peritonitis due to gastric ulcer perforation. This case highlights the importance of careful clinical evaluation and a multi-disciplines approach in patients with high ascitic Amylase levels especially in limited-resources areas in order not to miss a diagnosis in which a surgical approach can be lifesaving. To the best of our knowledge, this is the first reported case of concomitant very high ascetic Amylase level and fungal peritonitis as a manifestation of gastric perforation.