University of Texas Health Science Center at San Antonio San Antonio, TX, United States
Andrea DeCino, MD1, Adam Hughston, MD2, Nicole Loo, MD3 1University of Texas Health Science Center at San Antonio, San Antonio, TX; 2UT Health San Antonio, San Antonio, TX; 3UT Health San Antonio (aka UTHSCSA), San Antonio, TX
Introduction: Spontaneous peritonitis (SP) occurs in 15-26% of hospitalized patients with ascites, typically secondary to bacterial infection. Rarely, it is caused by fungal infection and carries a significantly higher mortality rate. We present a case of spontaneous fungal peritonitis (SFP) in a patient with cirrhosis.
Case Description/Methods: A 53-year-old man presented with one day of abdominal pain. Past medical history included alcoholic cirrhosis decompensated by ascites and complicated by untreated hepatocellular carcinoma. He was tachycardic to 103 beats/min and tachypneic to 29 breaths/min. Physical examination was remarkable for diffuse abdominal tenderness and a positive fluid wave. Initial laboratory studies revealed elevated aspartate aminotransferase (106 U/L), alanine aminotransferase (90 U/L), alkaline phosphatase (347 U/L), and total bilirubin (1.8 mg/dL). Following collection of blood and ascitic fluid cultures, ceftriaxone was started empirically for presumed spontaneous bacterial peritonitis (SBP). The absolute neutrophil count (ANC) was 1708 cells/mcL on ascitic fluid analysis. Initial cultures of blood and ascitic fluid were negative.
A diagnostic paracentesis was repeated on day four of admission due to clinical decompensation. The ANC had increased to 8796 cell/mcL, and these cultures grew Candida albicans and Candida dubliniensis after four days. Blood cultures remained negative. The patient elected to pursue comfort measures and was discharged home with hospice.
Discussion: SP is an infection of the ascitic fluid without a known intra-abdominal source. Fungal infection accounts for 5-22% of SP and has been mostly described in peritoneal dialysis patients. It is less commonly seen in patients with ascites secondary to cirrhosis, accounting for 2-10% of cases. Candida spp. cause the majority of infections, primarily by translocation from the gut lumen.
Severity of cirrhosis is a risk factor for development of SFP, due to relative immunosuppression. Diagnosis is often delayed and is made by fungal growth on ascitic fluid with an ANC of > 250 cells/mcL. Appropriate therapy is often delayed due to slow fungal growth on routine cultures and typical empiric treatment of SBP with a third-generation cephalosporin. Diagnosis requires a high index of suspicion, particularly if a patient fails to improve after 48 hours of appropriate antibiotics.
Given a 30-day mortality rate of up to 73%, empiric antifungal coverage in high-risk patients has been suggested, though more research is needed.
Disclosures: Andrea DeCino indicated no relevant financial relationships. Adam Hughston indicated no relevant financial relationships. Nicole Loo indicated no relevant financial relationships.
Andrea DeCino, MD1, Adam Hughston, MD2, Nicole Loo, MD3. P1929 - A Case of Spontaneous Fungal Peritonitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.