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Paper text:
ambulatory peritoneal dialysis is the preferred form of dialysis in countries where the facility of maintenance hemodialysis is limited .
infections in the form of peritonitis , exit site infections and tunnel infections are the most common problems with peritoneal dialysis . although gram - positive bacilli are the most common cause of peritonitis , they can also be caused by gram - negative bacilli , while fungi accounts for about 5 - 10% cases of peritonitis .
peritonitis secondary to zygomycosis has been reported only as case reports and till date about 16 cases have been reported in the world literature .
we report a case of peritonitis secondary to zygomycetes infection , which was managed successfully with the help of surgery and amphotericin b. earlier , two cases of zygomycetes associated peritoneal dialysis infection have been reported from india ; however , both of them succumbed , making our case probably the first from india to have survived this infection .
a 46-year - old male with end stage renal disease secondary to iga nephropathy had been started on continuous ambulatory peritoneal dialysis ( capd ) 6 years back .
he was using the twin bag system ( baxter healthcare , mcgaw park , illinois , usa ) , and was doing 4 exchanges / day .
3 years after starting on capd , he developed an episode of bacterial peritonitis , which was managed successfully with antibiotics .
currently , he presented with 3 days history of severe abdominal pain with high grade fever and turbid effluent .
meropenem and vancomycin which he received for 48 h before presenting to us . at presentation
his capd fluid analysis showed 1050 cells with 75% polymorphs while the fluid culture was sterile .
antibiotics with no response . repeat capd effluent bacterial and fungal cultures , acid fast staining and mycobacterial culture ( collected later ) were sterile .
after 72 h , due to non - response , his capd catheter was removed and he was continued on i.v . antibiotics . despite these measures
, he continued to have high grade fever . at the end of 1 week ,
a usg guided ascitic tap drained thick pus , following which a pigtail catheter was inserted in the largest of loculi , which failed to drain the collection . due to persistence of fever and loculated pus collections , he underwent open laparotomy .
intra - operatively , multiple loculated fluid collections with dense adhesions between bowel loops and peritoneum were noted [ figure 1a ] .
the peritoneal and omental biopsy taken intra - operatively revealed large areas of necrosis along with broad aseptate fungal hyphae consistent with zygomycosis [ figure 1b ] .
he received a total of 3 g amphotericin b and was doing fine at 6 months follow - up .
( a ) intra - operative photograph showing dense adhesions between bowel loops and peritoneum .
fungal peritonitis , accounts for about 5 - 10% of capd peritonitis across different series . about 80 - 90% of the episodes
are caused by candida species , while among the filamentous fungi , aspergillus is the most common .
fungal peritonitis poses a real problem to the nephrologists and mycologists with its relatively high mortality rate ( 5 - 15% ) and significantly high permanent capd discontinuation rate ( about 40% patients shifted to hemodialysis ) .
infection by zygomycetes group is extremely rare and till date about 16 cases have been described [ table 1 ] .
risk factors include previous antibiotic use , uncontrolled diabetes mellitus and desferrioxamine therapy . since our patient was on i.v .
antibiotics for about 1 week only , we do nt think that this may be a predisposing factor for development of fungal peritionitis in our case .
due to the same reason , our patient did not receive any antifungal prophylaxis . clinical profile and outcome of published cases of zygomycetes
peritonitis the clinical presentation of these patients is not different from an episode of usual bacterial peritonitis with pain abdomen , fever and cloudy effluent , however , these patients fails to improve after adequate empirical antibiotic therapy for suspected bacterial peritonitis .
the diagnosis is most cases was made by culturing the organism from the capd effluent , however , only in few cases a tissue invasion was documented . in our case ,
direct tissue invasion was documented and the large amount of tissue necrosis noted was consistent with the capacity for vascular invasion of this fungus . in all the other previous cases ,
amphotericin b , either conventional or liposomal was used as an initial treatment with duration of therapy of 12 weeks [ table 1 ] .
there is now some evidence that in amphotericin resistant cases , posaconazole is an effective drug and at least 60% of the amphotericin resistant cases can be salvaged by posaconazole therapy .
whatever be the antifungal therapy , the role of source removal in the successful management of these patients can not be overemphasized . in our case also , quick removal of the capd catheter as well as laparotomy and drainage of the intra - abdominal abscesses were helpful in the successful outcome .
the outcome of zygomycetes peritonitis is very dismal , with 11 of the 16 cases succumbing to the infection , while none of the surviving patient was able to go back on peritoneal dialysis .
our case is probably first from india documenting a successful outcome with the help of surgery and conventional amphotericin b. thus , a high index of suspicion in non - resolving peritonitis is required for diagnosing zygomyceteal peritonitis . if culture negative peritonitis gets complicated , we may need to suspect other unusual causes of peritonitis like an invasive fungal infection or mycobacterial infection .
early documentation of fungi with the help of peritoneal dialysis effluent culture or peritoneal biopsy , rapid institution of antifungal therapy and a low threshold for surgery are key parameters for a successful outcome of these patients .
we present a case of capd peritonitis caused by zygomycetes infection . a 46-year - old male patient presented with refractory peritonitis requiring catheter removal . 
 he had persistence of fever and an ultrasonography abdomen done revealed loculated collections . an initial pigtail drainage followed by open laparotomy was performed . 
 intra - operative peritoneal and omental biopsy revealed large areas of necrosis with broad aseptate fungal hyphae consistent with zygomycosis . 
 he was managed with 3 gm of intravenous amphotericin and is doing well at 6 months of follow - up .