Ciprofloxacin as Adjunctive Agent in Treating Cryptococcal Peritonitis

Abstract

Editor: Fungal infections leading to peritonitis in patients treated with peritoneal dialysis (PD) are associated with relatively high morbidity and mortality (1). Cryptococcus neoformans is regarded as a rare cause of peritonitis in patients on PD, with only a few cases reported in the literature (2‐5). Despite that, it remains a significant problem for physicians treating PD patients, since antifungal drugs, even when combined and implemented in high doses, are frequently insufficient and the disease can spread into general infection, with special predilection for the central nervous system and lungs (4). A 44-year-old patient with systemic lupus erythematosus on steroid therapy, who had been on automated PD for 3 years, was admitted to our department because of cryptococcal peritonitis. She presented with general malaise, abdominal pain, and vomiting, her temperature reaching 38.5°C. Abdominal x ray showed features of subileus. Computerized tomography revealed segmental infiltration of the jejunum. Dialysis effluent was cloudy, with 1200 white cells/μL. White blood cell count was found to be 12 700/μL, with 92% granulocytes. Culture showed yeast-like cells in the effluent, which 1 day later were diagnosed as C. neoformans. The Tenckhoff catheter was removed immediately, steroids dosage was decreased, and liposomal amphotericin B and fluconazole were introduced, both drugs given as 100 mg intravenously (IV) daily. As the patient’s general state gradually worsened, laparotomy was performed with extensive abdominal lavage. The drain was left in the peritoneal cavity. Again, C. neoformans was cultured from the lavage. After the surgery, her antifungal therapy was changed. Fluconazole was replaced by flucytosine 1 g IV every other day. The peritoneal cavity was washed through the drain once daily with fluconazole solution. Amphotericin B was continued without any change. However, after 10 days of such treatment, the patient’s condition did not improve. Her temperature was still high, abdomen distended, and bowel sounds hardly audible. Having no other therapeutic options concerning antifungal drugs, and given the information in the literature, we introduced ciprofloxacin 100 mg IV twice daily.