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Kidney Week

Abstract: PO1285

A Rare Case of Trichoderma-Related Peritonitis in a Patient on Peritoneal Dialysis

Session Information

Category: Trainee Case Report

  • 703 Dialysis: Peritoneal Dialysis

Authors

  • Bachu, Ramya, Baptist Health - UAMS Medical Education Program, North Little Rock, Arkansas, United States
  • Hemmings, Stefan Ceru, Baptist Health - UAMS Medical Education Program, North Little Rock, Arkansas, United States
  • Siddamreddy, Suman, Baptist Health - UAMS Medical Education Program, North Little Rock, Arkansas, United States
Introduction

Trichoderma spp are saprophytic fungi commonly found in the soil, decaying wood and humid environments. They are known to cause infections in immunocompromised hosts but rarely in peritoneal dialysis (PD) patients. Cases are infrequently reported in the literature and are associated with high morbidity and mortality.

Case Description

A 65yo white male with DM, HTN, HLD, ESRD on PD, was admitted with worsening abdominal pain for 4 weeks with low grade fever, chills, nausea and vomiting. His vitals were stable. Significant findings were a diffusely tender abdomen without guarding, rigidity or rebound tenderness. His PD effluent was cloudy. Labs were unremarkable. CT abdomen was negative for acute pathology. He was started on intraperitoneal vancomycin and ceftazidime as an outpatient as he had two earlier bacterial peritonitis episodes in the year. However, preliminary cultures from his clinic grew fungal elements. This prompted urgent PD catheter removal and conversion to hemodialysis. The fungus indentified was Trichoderma and he was started on IV Anidulafungin. Repeat PD cultures were negative and he was discharged on oral Voriconazole with follow up in ID clinic. Over the course of 2 weeks, he was readmitted twice with worsening abdominal pain. On the third admission, he had exploratory laparoscopy and found to have diffuse thrush like plaques all over the peritoneum. IV amphotericin B was added to inpatient antifungal regimen. However, he continued to deteriorate and elected to go home on hospice and passed away soon after.

Discussion

Diagnosis of fungal peritonitis in PD is challenging and oftentimes delayed. Occurrences usually follow treatment of bacterial peritonitis and mimics its clinical features. Most isolates of Trichoderma spp have shown resistance to fluconazole and 5- Fluorocytosine but show intermediate susceptibility to Amphotericin B, Itraconazole, Ketoconazole and Miconazole. Therefore, it is important to perform antifungal susceptibility tests and then adjust the final treatment.

In conclusion, Physicians who treat patients on PD should be aware of the possibility of this opportunistic infection. Prompt antifungal treatment should be considered in cases of recurring peritonitis in the appropriate patients. More research is needed to guide early diagnosis and guide effective treatment of this rare fungal disease with high mortality.