Paecilomyces puntonii fungal peritonitis

A 61-year-old hypertensive woman on continuous ambulatory peritoneal dialysis (CAPD) with a swan neck Tenckhoff catheter for the past 2 years undergoing four exchanges/day, and on anti-tuberculous treatment presented with poor drainage of the dialysate effluent for 5 days. At presentation, a cheesy material was seen in the catheter with cloudy effluent and poor inflow–outflow. The exit site and tunnel were normal. The dialysate fluid cell count was 300 cells/mm with neutrophils 36% and lymphocytes 64%. Fungal culture showed filamentous molds growth after 48 h. The catheter was removed and a peritoneal biopsy was done which showed mild focal fibrosis with chronic inflammation. She was switched over to hemodialysis and initiated on oral voriconazle 200 mg twice daily for 8 days. Fungal culture on Sabauraud’s agar showed slowgrowing spreading colonies brownish in color. Lactophenol Cotton Blue mount revealed conidiophores on simple bearing whorls of conidiogenous cells which were swollen. Chlamydospores were smooth walled and borne singly, identifying them as Paecilomyces puntonii (Figure 1). After 2 months, using a laparoscopic method, a Tenckhoff swan neck double cuff catheter was reimplanted as there were no adhesions. The patient was reinitiated on CAPD using 2 L exchanges of dineal four times a day. She has a good ultrafiltration with a volume of 1200 mL/day and is doing well. The genus Paecilomyces may be distinguished from closely related Penicillium by having long, slender, divergent phialides and colonies that are never typically green. Incidence of fungal peritonitis in India may be found in as many as 24% of cases of peritonitis [1]. The risk factors for fungal peritonitis in peritoneal dialysis are prolonged usage of antibiotics, and previous bacterial peritonitis. Catheter removal immediately after fungi are identified by microscopy or culture is recommended [2].