Spontaneous Peritonitis And Escalating Therapy From Bacterial To Fungal: A Case Report And Review Of The Literature
Here we present a case of spontaneous fungal peritonitis, initially misdiagnosed as spontaneous bacterial peritonitis, and a review criterion for patients requiring early empiric antifungal therapy.
A 67 year old diabetic man with decompensated NASH cirrhosis and CKDIII presented with acute kidney injury, abdominal pain and tenderness suggestive of spontaneous bacterial peritonitis (SBP) - Rocephin was started empirically. Paracentesis revealed >4000 PMNs, confirming SBP. A Nephrology consultant diagnosed hepatorenal syndrome type 1.
On day 2, during hemodialysis, his mental status deteriorated and he developed respiratory distress and hypotension. Emergently transferred to the ICU for intubation, clinicians added Vancomycin, Cefepime and Flagyl for septic shock. At 48 hours, follow-up paracentesis demonstrated 3600 PMNs, suggesting failure of SBP therapy. Candida glabrata grew from the initial paracentesis culture on day 3 and empiric Micafungin therapy was initiated. On day 4 his clinical status worsened, prognosis appeared dismal, and the family elected comfort care.
Effective medical therapy for SBP lacks coverage for spontaneous fungal peritonitis (SFP). When SBP therapy fails, SFP becomes a consideration. Mortality of SFP remains high at 50-100% due to the delay in culture-based fungal therapy initiation. Literature suggests antifungal initiation at 48 hours does little to change initial prognosis, thus earlier initiation might improve the outcome. Consider ascitic fluid fungal PCR for early diagnosis when SFP is suspected. We present criteria that can delineate patients at high risk for SFP so that early initiation of empiric antifungal therapy might improve overall prognosis.