AspergillusPeritonitis Complicating Continuous Ambulatory Peritoneal Dialysis

Dr. M. Pérez-Fontán, Servicio de Nefrología, Hospital Juan Canalejo, Xubias de Arriba 84, E-15006 A Coruña (Spain) Dear Sir, Fungal peritonitis represents one of the most feared complications of continuous ambulatory peritoneal dialysis (CAPD), given its significant mortality, and the frequent impossibility for continuation of peritoneal dialysis in survivors [1]. Most of these infections are caused by different yeasts of the species Candida [1,2], but the list of fungi causing peritonitis in CAPD is continuously expanding [1]. Filamentous fungi of the species Aspergillus are a rare cause of peritonitis in CAPD, seemingly producing particularly severe infections, with a high mortality rate [3–5]. We report on a case of Aspergillus peritonitis complicating CAPD, with a rapid favorable course once the peritoneal catheter was removed, even in the absence of effective antifungal therapy. The patient could reas-sume CAPD 2 months later, with a well-preserved peritoneal function and no evidence of relapse to date. Case Report A 69-year-old white male, with severe coronary heart disease and nephroangiosclerosis-related chronic renal failure, was started on CAPD in September 1987. During the following 2 years, his clinical course was complicated by severe relapsing angina pectoris, which markedly limited his physical activity, leading to inadequate rehabilitation and progressive obesity. The patient presented no episode of peritonitis or catheter exit-site or tunnel infection during this period. On December 4,1989, the patient experienced the sudden onset of fever, diffuse abdominal pain and, subsequently, cloudy dialysate effluent. He was evaluated on an ambulatory basis the same day. The most relevant findings on physical examination were: stable hemodynamic situation, febricula (37.5 °C), diffuse abdominal tenderness, and a noninflammated catheter exit-site. The dialysis effluent was cloudy, containing 1,940 cells/mm3 (43% polymor-phonuclear leukocytes, 32% histiocytes, 14% lymphocytes and 11% eosinophils). Dialysate samples were obtained for microbiological study, and therapy with intraperitoneal ciprofloxacin (50 mg/l dialysate) was begun. Abdominal pain, febricula and cloudy dialysate persisted, and the patient was admitted on the 4th day of evolution. The next day, fungal growth on a dialysate sample was detected; ciprofloxacin was discontinued, and intraperitoneal am-photericin (2 mg/l dialysate) and oral ketoconazol (200 mg b.i.d.) were begun. Subsequently, four samples of dialysate (days 1–5) grew Aspergillus sp. On the 10th day, and due to lack of response to antifungal therapy, the