Case Presentation: We present a 68-year-old woman who was in her usual state of health until July 2019 who presented with abdominal pain, back pain along with unintentional weight loss. Imaging revealed a mass in her pancreatic body which was confirmed with EUS and biopsy as invasive pancreatic adenocarcinoma. In late August, she presented with jaundice and worsening abdominal pain and was diagnosed to have extensive intrahepatic biliary dilatation. ERCP was attempted, although this was unsuccessful and she eventually had a percutaneous biliary drain placed. In early September, she was started on gemcitabine and abraxane for her pancreatic adenocarcinoma. A few days later, she was noted to have a perihepatic biloma when her initial drain was dislodged and a second drain was placed. At this time, she was also started on SBP prophylaxis with ciprofloxacin. She returned to the hospital a few weeks later with nausea, vomiting, generalized abdominal pain, and failure to thrive. Imaging showing worsening ascites with associated enhancement of the peritoneum. She underwent diagnostic paracentesis and was started on intravenous ceftriaxone for Spontaneous Bacterial Peritonitis. Fluid studies showed 98% polys, 4778 nucleated cell count and 78,250 RBCs. Her cultures later came back positive for Candida albicans following which Infectious Diseases was consulted and the patient was started on intravenous caspofungin. She was later transitioned to oral fluconazole and discharged to inpatient hospice.
Discussion: Fungal peritonitis is noted to be prevalent in 1 to 15% of patients undergoing peritoneal dialysis. However, the incidence in non-dialysis patients is rare. There have only been a few case reports that have discussed fungal peritonitis in association with intra-abdominal malignancies. There are two types of fungal peritonitis: primary and secondary. Primary disease occurs when there is no apparent breach in the gastrointestinal tract causing the organism to translocate into the peritoneum. Secondary fungal peritonitis is related to a pathologic process in a visceral organ, such as perforation, trauma, or local abdominal infections. Aside from peritoneal dialysis, other risk factors include immunosuppression, abdominal malignancy, prolonged antibiotics, previous bacterial peritonitis, and bowel source infections. Our patient had secondary fungal peritonitis due to biliary drains and manipulation of the drains multiple times, with the additional risk factors of abdominal malignancy and immunosuppression. Overall, 70-90% of the cases with fungal peritonitis are attributable to Candida albicans. Treatment is initially with echinocandins which can be later de-escalated based on sensitivities.
Conclusions: A high index of suspicion along with prompt diagnosis of fungal peritonitis in high risk patients is essential to reduce morbidity and mortality. Positive cultures in these patients should be treated immediately and not dismissed as a contaminant.