Visible Penicillium spp. colonization plaques on a Tenckhoff catheter without resultant peritonitis in a peritoneal dialysis patient

Jenq-Wen Huang1, Tzong-Shinn Chu2, Ming-Shiou Wu2, Yu-Sen Peng2 and Bor-Shen Hsieh2,

Departments of Internal Medicine, 1 Far Eastern Memorial Hospital, and 2 National Taiwan University Hospital, Taipei, Taiwan, ROC



   Introduction
 Top
 Introduction
 Case
 Discussion
 References
 
Although advances in the design of exchange systems have lowered the incidence of peritonitis, the disease is still responsible for about 16% of deaths in PD patients, especially those involving Gram-negative bacilli and fungi [1], and an even higher percentage of PD patients need catheter removal due to refractory peritonitis. Examination of these removed catheters revealed obvious micro-organism colonization, which may be the underlying cause of treatment failures due to its inherent antibiotic resistance [2]. However, whether a correlation exists between biofilm formation and clinical peritonitis remains controversial [2].

Although fungal peritonitis contribute to less than 10% of all episodes of peritonitis, these infections carry a mortality rate of 17–25% [3]. In some cases, fungi may colonize on the peritoneal catheter without causing peritonitis [46]. Herein we report the case of a chronic PD patient in whom Penicillium spp. hyphae had colonized on the luminal surface of the mini-transfer set and Tenckhoff catheter. Although Penicillium could be a pathogen of PD peritonitis [7,8], as in a recent report [9], no evidence of peritonitis was found in the present case except for the visible grey plaques on the Tenckhoff catheter. This case provides confirmation that Penicillium colonization on the catheter alone might not result in peritonitis.



   Case
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 Introduction
 Case
 Discussion
 References
 
A 42-year-old male uraemic patient was admitted to this hospital after his observation of greyish spots on the Tenckhoff catheter and mini-transfer set for several weeks. He had developed proteinuria at the age of 24, and his renal function had progressively deteriorated in the following 10 years. He started continuous ambulatory peritoneal dialysis (CAPD) at the age of 34. An operation for left hydrocele was performed 3 years after the commencement of CAPD, and he was post-operatively transferred to nocturnal intermittent PD with a cycler. Two months prior to this admission, he noted some greyish spots on the inner surface of mini-transfer set. The spots increased in size, and the mini-transfer set was replaced with a new one. However, similar plaques developed on the new set 2 weeks later. At the same time, similar plaques were also noted on the inner surface of the Tenckhoff catheter. The dialysate effluent outflow was smooth and no abdominal symptoms were noted. The effluent was clear and revealed no white cells or evidence of micro-organisms on routine examination. Penicillium spp. were isolated from the effluent cultures, and the Tenckhoff catheter was removed immediately; however, the culture of dialysate obtained by direct paracentesis did not reveal any pathogens. Microscopic examination of the removed Tenckhoff catheter showed entangled hyphae invading the catheter wall. The hyphae were intermingled with the plaques of crystal deposition.

The patient was placed on haemodialysis after catheter removal and did not receive any antifungal therapy. A new Tenckhoff catheter was implanted 1 year later, and the patient resumed peritoneal dialysis uneventfully.



   Discussion
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 Introduction
 Case
 Discussion
 References
 
Penicillium spp. are frequently found in soil, on decomposing organic debris, and often as airborne contaminants in the laboratory, but rarely cause human infection except in immunocompromised hosts. Only a few cases of PD peritonitis caused by Penicillium have been reported previously [7,8]. Catheter removal and antifungal therapy are needed to cure these cases of Penicillium peritonitis. However, Penicillium may also colonize only on the Tenckhoff catheter, without subsequent development of peritonitis [9]. In the present case, neither peritoneal sign nor cloudy effluent was observed despite the finding of fungi in the effluent culture, and Penicillium should therefore be considered as a colonizer other than a true pathogen.

A review of the literature found that Fusarium moniliforme, Fusarium oxysporum, Curvularia lunata, Aspergillus fumigatus, and Helminthosporium spp. have all been reported to be able to form visible fungal colonization [5]. The later three fungi colonized in a similar manner to the present case and did not cause peritonitis [46]. It had been proposed that these organisms are only weak pathogens without the capability to cause peritonitis [5]. Visible masses in the PD catheter with resultant partial obstruction caused by Penicillium have been previously reported in two patients with peritonitis [7,8] and in another patient with colonization only [9]. Among these cases, microscopic examination revealed that the catheter was colonized by a fibrous mass composed of entangled hyphae, as in the present case. Because Penicillium is a known pathogen of PD peritonitis, we removed the catheter immediately once a positive culture was obtained.

Since drug penetration through a stable biofilm is limited, its presence can result in recurrent peritonitis by the same organism [2]. In the present case, although it was not demonstrated that the fungi had created a biofilm, the penetration of hyphae into the inner wall of the catheter might have predicted the resistance to chemotherapy. It was also surprising that the colony reappeared on the new catheter within 2 weeks of replacement. Some authors have postulated that substances produced by fungi can weaken the Silastic walls of a Tenckhoff catheter, resulting in hyphal penetration [4]. Further investigation of the interaction between fungi and silicon rubber tube is needed.

Although fungal colonization does not always cause clinical peritonitis, as in the present and in other cases [46,9], the risk of development of fungal peritonitis, which is especially difficult to treat, indicates that the catheter should be removed in all cases. Although partial removal of the involved portion of the catheter has been successfully used to treat fungal colonization and peritonitis [6], this treatment places the patients at increased risk of recurrence on the replacement catheter. Furthermore, as in the present case, the condition of the Tenckhoff catheter is difficult to asses in situ, and partial removal may delay the definitive cure. Intracatheter retention of amphotericin B can cure the fungal peritonitis in some cases [10]; however, the success of this treatment may depend on the depth of hyphal penetration.

In conclusion, the present case confirms that Penicillium colonization on the PD catheter does not necessarily cause clinical peritonitis. This is the second reported case of such colonization without resultant peritonitis. Immediate catheter removal is essential to prevent the possible catastrophic complication of fungal peritonitis, and is an emergency in those patients who already have peritonitis or obstruction. The use of antifungal agents is not indicated in asymptomatic patients, as the infection is likely to be confined to the catheter. Although intracatheter amphotericin B retention is an alternative to catheter removal, the efficiency of this treatment remains unclear. Reimplantation can be performed if there is no evidence of fungal infection.



   Acknowledgments
 
The authors would like to thank the Ta-Tung Kidney Fund and Mrs Hsiu-Chin Lee Kidney Research Foundation for financial support.



   Notes
 
Correspondence and offprint requests to: Bor-Shen Hsieh MD, Medical College, National Taiwan University, No. 1 Jen-Ai Road, Section 1, Taipei 100, Taiwan, ROC. Back



   References
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 Introduction
 Case
 Discussion
 References
 

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Received for publication: 11. 8.99
Revision received 19. 6.00.



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