Exit site infection due to Zygomycosis resulting in abdominal wall necrosis in a continuous ambulatory peritoneal dialysis patient

Abstract

Keywords: continuous ambulatory peritoneal dialysis;exit site infection; zygomycosisA 52-year-old gentleman, type 2 diabetic andhypertensive was initiated on continuous ambulatoryperitoneal dialysis (CAPD) in August 2004. He waspartially blind in both eyes owing to diabeticretinopathy. He had also been confined to bed forthe past 2 months, due to severe sensorimotorperipheral neuropathy. His wife and son were perform-ing the exchanges, three per day with 2.5% dextrosesolution of Dianeal (Baxter India Pvt Ltd, New Delhi).He had Kt/V of 1.8 per week and a urine output of350–500ml/day. He had suffered an episode ofperitonitis in September 2005. Methicillin-sensitivecoagulase negative staphylococci was identified atthat time. He was injected with vancomycin 1g IPonce in every 5 days (three doses were given) and withceftriaxone 1g IP in the longest CAPD exchange for 14days. In December, the dermatologist of our Institutediagnosed him with infected scabies, when hepresented with complaints of overall body itching.He had burrows and infected scratch marks all over hisbody. He was prescribed permethrin, liquid paraffinand gamma benzene hexachloride soap. In the lastweek of the same month, he presented to us witherythema and blackening of the skin, starting initiallyaround the exit site and the tunnel and spreading to theentire anterior abdominal wall in a week, resulting infull thickness necrosis and sloughing, exposing therectus and other anterior abdominal muscles (Figure 1and 2). He also complained of abdominal pain, cloudyeffluent of 1-day duration, vomiting of 3-day duration.The results of investigations done were: haemoglobin,7.1g/dl; blood urea, 91mg/dl; creatinine, 5.1mg/dl;serum proteins, 5.6g/dl; serum albumin, 1.7g/dl. TheCAPD catheter was removed. The catheter tip cultureshowed the growth of zygomycetes. The histopathol-ogy of the specimen from wound tissue also revealedthe growth of zygomycetes. Detailed mycologicalidentification was not possible at our institute. Thepatient was initiated on haemodialysis and twice a daycleaning and dressing of the wound with EdinburghUniversity solution of lime (EUSOL), as is the practiceat our institute, and amphotericin. EUSOL isa solution of calcium hypochlorite containing notless than 0.25% w/v of available chlorine bufferedwith boric acid to a pH of 7.5–8.5. After 3 weeks oftreatment, the signs of peritonitis subsided. When theplastic surgeon contemplated thorough debridementunder general anaesthesia, the patient’s general condi-tion was so deteriorated owing to malnourishmentthat his son refused further treatment and he left theInstitute against medical advice.There are very few reports [1–4] of peritonitis andexit site infection due to zygomycosis. In all instances,the catheter had been removed. Mortality related tozygomycosis has been reported as 57% [5].The human infection is rare, despite ampleexposure to zygomycosis, due to efficacy of theimmune system. Underlying factors include diabetic