HYPHOPICHIA BURTONII: A NOVEL PATHOGEN IN SECONDARY PERITONITIS

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: We present a case of secondary peritonitis (SP) due to intestinal infarction from bowel ischemia in a patient with decompensated alcoholic cirrhosis. Differing from spontaneous bacterial peritonitis (SBP) based on presence of a surgically treatable abdominal infectious source, SP is less common than SBP and carries a 3-fold higher risk of in-hospital death (1). CASE PRESENTATION: A 63 year-old man with decompensated alcoholic cirrhosis and a ventral hernia presented to an outside hospital with altered mental status and gastrointestinal bleeding. On hospital day (HD) 1, he underwent esophagogastroduodenoscopy with variceal banding and was treated empirically with piperacillin/tazobactam. On HD 3, paracentesis showed: WBC 4,046 mm3, 96% PMNs, culture positive for Klebsiella pneumoniae and Enterobacter cloacae resistant to piperacillin/tazobactam; he was transitioned to meropenem. He underwent 8.3L paracentesis on HD 7, and was transferred to our hospital on HD 9 for liver transplant evaluation. On arrival, he had stable vitals, West Haven grade III encephalopathy, a ventral hernia, and large ascites without tenderness to palpation. Pertinent labs: WBC 25,600 mm3, Na 156, BUN 78, and Cr 2.07 and MELD-Na of 24. On HD 10, repeat 4.0L paracentesis revealed: WBC 11,385 mm3, 95% PMNs, with cultures growing Candida guilliermondii. Micafungin was initiated and meropenem continued. On HD 13, due to worsening mental status and septic shock, he was transferred to the ICU and intubated. Pertinent labs: WBC 26,800 mm3, Na 140, BUN 98, and Cr 4.09. Repeat paracentesis yielded 2.2L of frank pus, with WBC 18,975 mm3 (no differential), microscopy showed mixed microbiota with budding yeast and gram positive cocci in pairs and chains. Micafungin was continued and daptomycin initiated. CT scan demonstrated ischemic and perforated bowel within the hernia. Despite aggressive measures, he died on HD 14. Among the peritoneal microbiota isolated, Hyphopichia burtonii predominated, speciating 6 days after death. DISCUSSION: To our knowledge, this case of SP due to intestinal infarction represents the first report of Hyphopichia burtonii as a human pathogen. The mixed microbiota on HD 13 raised concerned for SP, prompting a CT scan which revealed intestinal infarction. Notably, our patient exhibited every key sign of SP: polymicrobial peritonitis, a poor response to antibiotics, uptrending PMNs on serial paracenteses, and abnormal imaging findings (2). Hyphopichia burtonii is a species of yeast known as a bread and dairy mold, and part of flora of cured meat. Hyphopichia burtonii has only been reported as the cause of cutaneous mycosis in a bat (3). CONCLUSIONS: We present a case of secondary peritonitis involving Hyphopichia burtonii, a yeast not previously known to be a human pathogen. Reference #1: Lu MLR, et al. Infected ascites: Distinguishing secondary peritonitis from spontaneous bacterial peritonitis in a cirrhotic patient with classic symptoms. IDCases. 2017;8:29-31. Published 2017 Feb 28. doi:10.1016/j.idcr.2017.02.010 Reference #2: Soriano G, et al. Secondary bacterial peritonitis in cirrhosis: a retrospective study of clinical and analytical characteristics, diagnosis and management. J Hepatol. 2010;52(1):39-44. doi:10.1016/j.jhep.2009.10.012 Reference #3: Simpson, V. R., et al (2013). Cutaneous mycosis in a Barbastelle bat (Barbastella barbastellus) caused by Hyphopichia burtonii. Journal of Veterinary Diagnostic Investigation, 25(4), 551–554. https://doi.org/10.1177/1040638713493780 DISCLOSURES: No relevant relationships by Shira Abeles, source=Web Response No relevant relationships by Amy Bellinghausen, source=Web Response No relevant relationships by Erica Feldman, source=Web Response No relevant relationships by Biren Kamdar, source=Web Response No relevant relationships by Irine Vodkin, source=Web Response