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Kidney Week

Abstract: FR-PO562

Getting Off on the Wrong Foot: Trichosporon inkin Peritonitis

Session Information

Category: Trainee Case Report

  • 703 Dialysis: Peritoneal Dialysis


  • Giehl, Nolan M., UC Davis Internal Medicine Residency, Sacramento, California, United States
  • Young, Brian Y., UC Davis Medical Center, Sacramento, California, United States

Peritonitis is a serious complication of peritoneal dialysis and 3-6% are fungal in etiology. Trichosporon inkin, a yeast-like fungus associated with the superficial hair shaft infection “white piedra,” seldom causes invasive infections. Treating invasive Trichosporon spp. can be challenging given limited data. We present a rare case and describe the treatment of resistant T. inkin peritonitis in an end stage renal disease (ESRD) patient on automated peritoneal dialysis (APD).

Case Description

A 56 year old man with ESRD from membranoproliferative glomerulonephritis on APD presented with abdominal pain and cloudy dialysate. PD fluid cultures were drawn and he was empirically treated for bacterial peritonitis with intraperitoneal cefazolin + ceftazidime, while nystatin was used for fungal prophylaxis. 6 days later, pain and cloudy fluid persisted, and his fluid culture grew Trichosporon inkin. The patient, who also had onychomycosis, later admitted to picking at his right 2nd toenail to remove a splinter prior to handling his PD catheter. The PD catheter was removed due to his fungal infection, and he was converted to HD. Initial use of IV micafungin failed to improve his symptoms. Testing showed the T. inkin to be resistant to Echinocandins, but susceptible to voriconazole. Voriconazole was given for 10 weeks with resolution of his symptoms and onychomycosis. Now off antifungals for 2 months, he is waiting re-evaluation to return to PD.


The etiology in our case was likely poor hand hygiene after manipulation of his toe. Multiple cases of Trichosporon spp. onychomycosis have been described but only 3 prior T. inkin peritonitis cases have been reported, the last in 2003 and treated with caspofungin. Voriconazole, FDA-approved in 2002, was used in our case as it performed best in vitro against T. inkin, which is typically resistant to echinocandins. Therapy duration is not as clear and has ranged from 2-8 weeks in the literature, often being anecdotal. T. inkin is also associated with biofilm formation, causing up to a 1000x higher MIC required by voriconazole in 1 in vitro model. With these concerns, the patient was treated with a lengthy course to give the best hope for cure and to restart PD eventually. This is the first case to describe voriconazole treatment in T. inkin peritonitis, with further research needed to define optimal therapy duration.