A Case of Capd-Related Cryptococcus Peritonitis after Kidney Transplant Failure

A 80-year-old man with severe atherosclerosis and chronic renal disease related to ischemic nephropathy gradually developed diabetes and uraemia six years after a kidney transplant. Immunosuppression included rapamycin 1 mg qd, mycophenolic acid 500 mg qd and prednisone 2.5 mg qd. When CAPD was started only low dose prednisone was maintained to preserve residual kidney function. Thirty days into CAPD, the patient presented with fever (38.4°C): the abdomen was tender, the PD catheter exit site was healthy, the peritoneal fluid was clear. Chest, abdomen and brain imaging were negative. He had blood (17.340/mm3,) and peritoneal fluid (190/mm3) leucocytosis, CRP was increased at 10.2 mg/dl. Blood, urine and peritoneal effluent cultures were collected and iv. ceftriaxone 2 g qd was administered. Three days later the fever had disappeared but CRP increased to 17.8 mg/dl and peritoneal fluid leukocytes rose to 600/mm3. On day 6 the peritoneal effluent culture grew Cryptococcus Neoformans. Intravenous liposomal Amphotericine B 200 mg/day and Flucytosine 2.5 g/day were administered for 4 weeks, with prompt clinical improvement. The PD catheter was removed, and hemodialysis was started.

Cryptococcal peritonitis is uncommon, with only 15 cases described in peritoneal dialysis (PD) patients out of 61 reported between 1951 and 2012, but infection with the pathogen is a recognized complication of immunosuppression. Diagnosis is often difficult while prompt treatment is required. This potentially severe infection should be considered in any PD patients with clinical signs of culture negative peritonitis and recent or ongoing immunosuppressive therapy.

Keywords: Peritoneal dialysis; fungal peritonitis; cryptococcus; solid organ transplant patients; failing kidney transplant.