D THARMARAJ1, C DENDLE2, K POLKINGHORNE1,3, M DAMASIEWICZ1,3
1Department of Nephrology, Monash Health, Clayton, Australia, 2Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University and Monash Infectious Disease, Monash Health, Clayton, Australia, 3Department of Medicine, Monash University, Clayton, Australia
Background: Fungal peritonitis is associated with significant morbidity and mortality and commonly leads to peritoneal dialysis (PD) technique failure. Candida albicans and Candida parapsilosis are the most common fungal organisms causing PD peritonitis. Clinical experience with rare candida species is important to inform practice because with clinical data lacking, recommendations are largely based on laboratory data. We present a case of Candida guilliermondii PD peritonitis.
Case Report: A 70-year old male was admitted for an elective arteriovenous fistula ligation. During his admission he developed a cloudy dialysate but remained clinically well with no fevers, abdominal pain or systemic symptoms. His peritoneal fluid microscopy revealed a white cell count of 1410 x 106/L, the gram stain showed no growth, and his culture isolated Candida guilliermondii. The fluconazole, voriconazole, amphotericin B and caspofungin minimum inhibitory concentrations (MIC) were 4mg/L, 0.06mg/L, 0.25mg/L, and 0.5mg/L respectively. The European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoints data suggests fluconazole resistance with MIC>4 mg/L for C.albicans and C.parapsilosis. The susceptibility data for C. guilliermondii is not yet clearly established. The patient underwent a removal of his Tenkhoff catheter and was successfully treated with a two-week course of oral fluconazole 200mg daily despite the potentially reduced invitro susceptibility, as inferred from other common candida species’ resistance patterns.
Conclusions: guilliermondii PD peritonitis is rare. It is reportedly a more resistant candida species with a diminished susceptibility to fluconazole and echinocandins. Lack of clinical experience may make interpreting susceptibility data of rare fungal pathogens unreliable. Although invitro results suggested potentially reduced fungal susceptibility, our case demonstrates that clinical cure is achievable with short course fluconazole therapy and Tenkhoff removal.
I’m currently a 3rd year Nephrology Advanced trainee at Monash Health and had completed my second year of training at Eastern Health. I have an interest in renal immunobiology and transplant medicine. Prior to MBBS I had completed a Bachelor of Radiography and Medical Imaging degree through Monash University.