Early Fusariosis after Peritoneal Dialysis Drain Placement

Introduction: Fusarium peritonitis has been reported in people with long-standing peritoneal dialysis (PD) catheters and usually occurs on average of 48 months after peritoneal drain placement. We present a case of invasive fusariosis manifested by Fusarium peritonitis within one week of peritoneal drain placement. Case Description: A 40-year-old man with chronic alcohol use was admitted to our intensive care unit with one-month history of vague abdominal pain. CT abdomen and pelvis revealed free intraperitoneal air in pelvis near the proximal rectosigmoid colon suggestive of ruptured diverticulitis with a potential loculated fluid collection as well as large volume ascites with a markedly enlarged cirrhotic liver. Paracentesis was performed and peritoneal fluid was sent for culture which was sterile. IR placed a peritoneal drain on day 11 and peritoneal fluid cultures were collected which showed growth of ampicillin susceptible E. faecium and Candida lusitaniae. On day 20, peritoneal cultures collected from day 15 showed growth of mold, and he was started on empiric liposomal amphotericin B. The mold was later identified as Fusarium and antifungal was switched to voriconazole. The family opted for comfort care and patient passed away on day 25 of the hospitalization. Discussion: One of the risk factors for developing Fusarium peritonitis is indwelling PD catheter as well as long-retained peritoneal drains for chronic dialysis. The optimal treatment of Fusarium remains unclear, but voriconazole, itraconazole or polyenes have been reported with some treatment success. Usually, it takes several months for the Fusarium infections to develop after a catheter placement, but in our patient, he developed fusarium peritonitis within 5 days of peritoneal drain placement. This early growth during hospitalization and lack of growth first sampling of peritoneal fluid suggests that the patient might have acquired it from the inpatient hospital setting. Fusarium should be on the differential for early peritonitis especially in patients with risk factors such as ESLD, chronic ascites and presence of a peritoneal catheter and empiric antifungals with activity against molds should be considered. Aggressive management of Fusarium peritonitis is essential to prevent disseminated disease.