Spontaneous Fungal Peritonitis Caused by Pichia norvegensis in a Patient With Budd-Chiari Syndrome and Noncirrhotic Portal Hypertension: A Case Report

Spontaneous fungal peritonitis (SFP) is an uncommon but potentially life-threatening complication of advanced liver disease, predominantly described in patients with cirrhosis.Pichia norvegensis (formerly Candida norvegensis) is a rare human pathogen for which clinical experience and antifungal susceptibility data remain limited.We report the case of a 52-year-old man with Budd-Chiari syndrome secondary to polycythemia vera progressing to myelofibrosis, advanced chronic liver disease, severe noncirrhotic portal hypertension, and a transjugular intrahepatic portosystemic shunt (TIPS).He presented with abdominal pain and fever following a recent hospitalization for gastric variceal bleeding, during which he had received ceftriaxone prophylaxis.Ascitic fluid analysis revealed marked neutrocytic peritonitis (11,798 polymorphonuclear neutrophils/µL), with negative bacterial cultures.P. norvegensis was identified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) in two separate ascitic fluid specimens.Antifungal susceptibility testing revealed a micafungin minimum inhibitory concentration of 0.031 mg/L; however, validated species-specific clinical breakpoints were unavailable.Empirical micafungin was administered at 100 mg intravenously daily for 22 days, with favorable clinical evolution, a progressive reduction in ascitic neutrophil counts, and a negative follow-up fungal culture.Concurrent portal hypertensive complications required TIPS revision.This case illustrates the occurrence of fungal peritonitis associated with an uncommon yeast in a patient with severe portal hypertension without histologically established cirrhosis.Although a secondary intraabdominal source could not be definitively excluded, repeated fungal isolation supported the clinical significance of the organism.The case highlights the importance of considering fungal infection in patients with neutrocytic ascites and negative bacterial cultures, as well as the need for reliable species identification and cautious interpretation of antifungal susceptibility results.