A successful management of fungal peritonitis caused by Rhodotorula glutinis in CAPD patient, coincident with onychomycosis by Penicillium sp: Case report

Abstract

Rationale: Rhodotorula glutinis is a rare cause of fungal peritonitis in peritoneal dialysis (PD) patients. The combination treatment between aggressive PD catheter replacement and adequate antifungal treatment is crucial in managing peritonitis due to fungal infection and onychomycosis. Patient concerns: A 37-year-old man PD patient presented with cloudy effluent, abdominal pain, and black debris in the lumen of his PD catheter. Twelve days before admission, the patient traveled for 10 days to a high-temperature country, Saudi Arabia, for purpose of accomplishing haj. From the physical examinations, there was an onychomycosis in his right toenail. Diagnoses: The result of the dialysate cell count confirmed the evidence of peritonitis (i.e., cell count of 187 cells per µL, however with polymorphonuclear 31%). The dialysate culture indicated R glutinis, with no growth of bacteria. Fungal culture of his toenail scrapings was obtained and the result was Penicillium sp. Interventions: Based on the high clinical suspicion of fungal peritonitis, fluconazole intraperitoneal (IP) was immediately given on the first day in addition to empirical antibiotics, that is, cefazolin and gentamycin IP. His peritoneal catheter was simultaneously removed and reinserted on the 4th day of treatment. Since there was a sign of fluconazole resistance, fluconazole IP was switched into oral voriconazole, without any antimicrobial treatment intraperitoneally. After 21 days of voriconazole, oral itraconazole was given until 3 months for his onychomycosis. Outcomes: Clinical improvement was seen on the effluent where the leucocyte count falls below 100 cells after 21 days of giving voriconazole. Lessons: This case report suggests the need for comprehensive evaluations of the risk for fungal infection in continuous ambulatory PD patients, especially those who live in a tropical country.