FUNGAL PERITONITIS IN THE SETTING OF NECROTIZING PANCREATITIS

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Spontaneous fungal peritonitis (SFP) is a fungal infection of ascitic fluid, defined as over 250 polymorphic neutrophils (PMNs) and fungal growth on culture. It has a high mortality rate and often is recognized late in clinical courses. SFP is commonly associated with cirrhosis or advanced end stage liver disease. This is due to perturbation of mucosal blood flow and bacterial growth in the intestines, and changes in the permeability of the mucosal wall of the gastrointestinal tract (1-3). However, amongst patients without cirrhosis, there is limited data describing patients with SFP. Herein we describe a patient with no history of cirrhosis presenting with necrotizing pancreatitis and ileus who developed SFP. CASE PRESENTATION: A 60-year-old woman with a past medical history of hypertension presented to our hospital unresponsive with septic shock. She was intubated, resuscitated, placed on vasopressors and treated with broad spectrum antibiotics. Further evaluation with laboratory data demonstrated a lipase > 4000 u/L. Computed tomography imaging was consistent with necrotizing pancreatitis, ileus and small bowel obstruction. Her course was complicated by development of a large phlegmon requiring cystogastrostomy for drainage, in addition to total parenteral nutrition (TPN). Despite drainage and antibiotics she continued to have worsening abdominal distension and vasopressor requirement. An abdominal ultrasound demonstrated loculated ascites with septations (a). An abdominal drain was placed with subsequent drainage of 2.2 liters of moss-colored ascitic fluid (b), with over 2000 PMNs and growth of Candida albicans, Enterococcus faecalis and Stenotrophomonas maltophilia. Her antibiotics were adjusted to fluconazole, oxacillin and minocycline. With subsequent drainage and appropriate antibiotics, her vasopressor requirement resolved, she was liberated from the ventilator and her mental status improved. DISCUSSION: We describe a patient who develops SFP without its commonly known risk factors. We suspect the use of broad-spectrum antibiotics during the patient's hospital course, in conjunction with mucosal breakdown of the enteral tract in the setting of ileus and severe necrotizing pancreatitis created a favorable environment for fungal overgrowth. TPN is not known to cause SFP specifically, but with fungal infections in general. Antibiotics in the setting of TPN use may have caused further alterations of microbial balance, increased fungal dominance (4-6) and resulted in microbial translocation and polymicrobial peritonitis. CONCLUSIONS: It is critical to recognize SFP in patients without liver disease. Other less common risk factors such as antibiotics, perturbation of the enteral tract with diseases such as pancreatitis, ileus and TPN can increase one's risk of SFP. Early recognition and treatment can improve patient outcomes in patients presenting with septic shock. REFERENCE #1: Patel D. et al. Spontaneous fungal peritonitis as a rare complication of ascites secondary to cardiac cirrhosis: a case report. Am J Case Report. 2019; 20:1526-1529. REFERENCE #2: Shizuma T. Spontaneous bacterial and fungal peritonitis in patients with liver cirrhosis: a literature review. World J Hepatol. 2018 Feb 27; 10(2): 254-266. REFERENCE #3: Lahmer T., Brandi A., Rasch S., Schmid RM., Huber W. Fungal peritonitis: underestimated disease in critically ill patients with liver cirrhosis and spontaneous peritonitis. PLoS ONE. 2016 July 8; 11(7).4. Van Leeuwen PA, et al. Clinical significance of translocation. Gut. Jan 1994; 31(1 Suppl):S28-34). Doi: 10.1136/gut.35.1_suppl.s28.5. Bernhardt H, Zimmermann K, Knoke M. The continuous flow culture as an in vitro model in experimental mycology. Mycoses. 1999;42 Suppl 2:29-32. PMID: 10865900.6. Yang S. et al. A risk factor analysis of healthcare-associated fungal infections in an intensive are unit: a retrospective cohort study. BMC Infectious Diseases. 2013; 13(10) DISCLOSURES: No relevant relationships by Andrew Deitchman, source=Web Response No relevant relationships by Austin Hager, source=Web Response No relevant relationships by Diane Wang, source=Web Response