Frequency of Fungal Peritonitis in Patients with End Stage Liver Disease
Authors: Monsef Abu El Magd Wahid Abd El , Abdelkader Nadia Abdelaaty , Ahmad Mostafa Abdelfattah Shamkh , Ahmed Omnia Mohamed Elnabawy 
Published: November 2024

Ascites is the most frequent symptom of liver decompensation (Cirrhosis). Spontaneous bacterial peritonitis (SBP) is an acute infection of the abnormally accumulated fluid in the abdomen (ascites) in the absence of an intra-abdominal source of infection and with no obvious source of bacteria. Spontaneous bacterial peritonitis is more common in patients with advanced cirrhosis. The bulk of the isolated species in SBP are gram-negative enteric organisms (e.g., Escherichia coli or Klebsiella pneumoniae), implying that the GI tract is the main source of infection. Enterotoxin is often extracted from ascitic fluid, lending credence to the idea that bacteria implicated in SBP move transmurally from the intestinal lumen (i.e., bacterial translocation). The most important risk factor is a prior episode of SBP; two thirds of patients will have a recurrence of infection within the following year, GI bleeding (specifically variceal hemorrhage), total protein in ascitic fluid lower than 1.0 g/dL which indicates low opsonic activity, severe liver cell dysfunction, and use of proton pump inhibitors.

Spontaneous fungal peritonitis (SFP) is characterized as fungal infection of the ascitic fluid and the presence of an ascitic neutrophil count of more than 250 cells/mL, which is a devastating and underappreciated complication of ESLD. When antibiotics are used to avoid SBP in patients with ascites, the intestinal bacterial flora is reduced, resulting in significant fungal colonization. This causes peritonitis by inducing translocation through the compromised gastrointestinal tract mucosa into peritoneal cavity. Immunosuppression and malnutrition, both of which are widespread in ESLD, intensify this impact. Since fungi are much larger than bacteria, a higher gut permeability is expected for fungal translocation. This is why SFP is most likely limited to those who have had the most damage to their innate immunity and who have advanced cirrhosis.

Due to the high mortality rate associated with SFP, early diagnosis and treatment are critical for optimizing patient outcomes. New tests, such as the pan- fungal PCR assay and 1,3 beta-D-Glucan, are not only more sensitive in identifying fungi in peritoneal fluid, but they also aid in the early detection of SFP by reducing the time to diagnosis. It is recommended to test peritoneal fluid of patients with risk factors for SFP early with these assays.

This study aimed to know the frequency of spontaneous fungal peritonitis in patients with end stage liver diseases. The study was done as a single center, prospective cohort study, in Tropical Medicine Unit, faculty of medicine, Ain Shams University Hospitals. All patients were subjected to full clinical assessment, laboratory investigations, abdominal ultrasonography, diagnostic abdominal paracentesis, examination of ascitic fluid and microbiological cultures. There was no statistical significance between the group of patients who have SFP and the group of patients who do not have SFP regarding demographic data.

There is no statistical significance between the two groups regarding clinical data. There is an increase in percent of fever (22.2%) in patients with SFP.

There was a statistical significance in spleen size between the patients with SFP and the patients without. There was no statistical significance between the two groups regarding presence or absence of HFLs, grade of ascites and presence of portal vein thrombosis.

There was no statistical significance between the two groups regarding laboratory parameters but there was a significant difference in the mean of CRP between the patients with SFP and the patients without SFP.

There was statistical significance between the two groups regarding ascetic TLC, ascetic neutrophil count, ascetic lymphocyte count, SAAG and exudate type. There is no statistical significance between the two groups regarding other ascetic parameters (protein, albumin, glucose, LDH).

There was a statistical significance between the two groups regarding the outcome of patients as mortality is significantly higher in the SFP patient group. Six patients died from SFP. Two of them were having both SFP and SBP.

There was no statistical significance between the two groups regarding location of the patient (in ward or ICU) as a risk factor to get SFP. There were seven deaths in ICU admitted patients, three of them had SFP.

In conclusion, the frequency of IFI in patients with ESLD was low; however, in patients with these infections, delayed diagnosis and treatment may have contributed to high fatality rates. Hence, to improve the outcome in these patients, clinicians should have a high index of suspicion for this unusual but lethal entity so that it may be detected early, and empiric antifungal treatment should be started, especially in high-risk patients, until appropriate treatment can be used.