P180 Is gene sequencing only way forward?
Authors: Dcoutho Camila , Savio Jayanti , Padakki Priyadarshini , M. Limesh 
Published: September 2022

Abstract

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

Introduction
Fungal peritonitis (FP) associated with peritoneal dialysis (PD) is an uncommon complication. Candida peritonitis accounts for 70%-90%. A total of 55 cases of Aspergillus peritonitis have been reported from 1968 to 2019 with A. fumigatus and A. niger as the most common isolates.
FP is associated with high mortality and often results in discontinuation of PD and switching to hemodialysis (HD).

Objectives
To identify and report the pathogen from peritoneal abscess.

Methods and Results
A 54-year-old post-menopausal lady, a known diabetic, hypertensive with chronic kidney disease (CKD) on PD for 2 years presents with acute onset breathlessness. She was dialyzed and improved. During her hospital stay, she developed a fever which was managed with intravenous antibiotics, piperacillin-tazobactam, teicoplanin, and fluconazole. The PD was bacterial culture negative. Patient improved on HD and was discharged.
A total of 10 days later she was readmitted due to complaints of fever. Her PD fluid analysis was clear with high leucocyte count. The same was sent for the presence of acid-fast bacilli and aerobic bacterial culture, both of which were negative. Her blood was sent for automatic aerobic bacterial culture which yielded no growth. Patient developed pain in abdomen and PD catheter was removed. Abdominal Computed Tomography (CT) imaging revealed a thick-walled intra-peritoneal collection in the left subdiaphragmatic region. In view of persistent fever, antibiotics were changed to meropenem, metronidazole, and amikacin. Pus aspirated was received for aerobic bacterial culture and fungal culture. KOH—Calcofluor examination revealed septate fungal hyphae. Bacterial culture yielded Enterococcus species sensitive to penicillin and gentamicin. Patient was treated with amphotericin B and HD. Repeat aspirate also revealed septate fungal hyphae. However, on both occasions fungal cultures were negative. She improved symptomatically and was discharged.
Sample was sent to Post Graduate Institute of Medical Education and Research, Chandigarh for the identification of the fungal pathogen directly from the sample using Gene sequencing. The pathogen was identified as A. niger.

Conclusion
Aspergillus peritonitis in a PD patient though rare is associated with high mortality and morbidity. They are often associated with concurrent or prior bacterial peritonitis. Treatment with antibiotics often predisposes to fungal peritonitis. Clinical presentation is similar to bacterial peritonitis, a high index of suspicion is warranted to establish the diagnosis. Identification of fungal pathogen to rule out species inherently resistant to certain classes of antifungals is critical for successful management. This is possible only by molecular methods, especially in culture-negative cases. In this case of culture-negative invasive fungal infection, the preliminary diagnosis was based on microscopic evidence of two consecutive samples. Gene sequencing helped us to confirm the diagnosis.