A case of Aspergillus fumigatus peritonitis in a patient undergoing continuous ambulatory peritoneal dialysis (CAPD): diagnostic and therapeutic challenges.

In the June 2004 issue of your journal, Scotter described a case of aspergillus peritonitis in a patient undergoing renal dialysis diagnosed by the polymerase chain reaction and galactomannan detection. We had a similar case of aspergillus peritonitis detected by (repeated) culture of peritoneal fluid and a positive serum galactomannan detection test. An 82 year old man under continuous ambulatory peritoneal dialysis was referred to our hospital because of chronic dyspnoea, persistent cough with production of white sputum, fever, and abdominal pain. He was known to have diabetes mellitus and corticodependent chronic obstructive pulmonary disease. He developed a documented polymicrobial bacterial peritonitis, which was adequately treated. A few days later Aspergillus fumigatus was repeatedly cultured from his sputum. A bronchial aspirate also yielded A fumigatus. Because of persistent abdominal pain, peritoneal fluid was cultured using BacT/ALERTH FA aerobic and SN anaerobic culture bottles (bioMérieux, Marcy-L’Etoile, France). Cultures repeatedly yielded A fumigatus. The dialysis catheter was removed and cultured on Sabouraud dextrose agar containing chloramphenicol; A fumigatus grew after two days of incubation. The galactomannan antigen detection test (PlateliaH Aspergillus; Bio-Rad, Marnes-LaCoquette, France) performed once on the patient’s serum revealed a positive value of 3.5 (normal value, , 0.8; doubtful, 0.8–1.0; positive, . 1.0). Oral voriconazole 400 mg twice daily was started promptly because peritoneal aspergillosis was considered very likely. Unfortunately, the patient died after 24 hours of antifungal treatment. Peritonitis caused by fungi of the Aspergillus spp is rare in patients with continuous ambulatory peritoneal dialysis and is associated with high mortality. Early detection, peritoneal catheter removal, and appropriate treatment with antifungal drugs may improve outcome. However, it is not clear whether voriconazole is the treatment of choice, because it has never been used in this setting, and there are no data available on voriconazole concentration in peritoneal fluid. Galactomannan detection in serum and maybe also in peritoneal fluid, in addition to the polymerase chain reaction (if available), may contribute to an early diagnosis.