Over the past 20 years, the incidence of fungal infections, both superficial and deep, has increased dramatically. These pathologies most often occur in immunocompromised patients (those who have undergone organ transplants, dialysis, bone marrow transplants, chemotherapy, those taking immunosuppressants, etc.). If the patients and the treatments have evolved, the fungi involved in the pathologies have also diversified. Indeed, we have observed the emergence of species previously unknown to the medical community, as well as the re-emergence of already known species.

The latter are responsible for new clinical forms, occurring in different in different circumstances [1]. Fungal peritoneal infection (PI) is a relatively rare but serious complication in peritoneal dialysis (PD). It is associated with a high risk of technical failure and death, especially in the case of late diagnosis [2]. A high mortality rate has been reported [3]. Although its prognosis is bleak, its prevalence is highly variable throughout the world, ranging from 2 to 23.8% in industrialized and developing countries, respectively [2]. In the entire RDPLF database, 1.2% of peritonitis cases over the last 10 years have been fungal, with no cases of Geotrichum [personal communication RDPLF]. Candida is the most common genus, implicated in 80% to 90% of cases of fungal PI [4]. Indeed, in Mexico, out of 149 cases of PI reported in 2013, 12 were of fungal origin. Of these, 6 were linked to Candida albicans. [5].

In India, the Candida genus accounted for 50% of fungal PI in CAPD [6]. Other fungi such as Fusarium, Aspergillus, Penicillium [7], Cryptococcus [8], have been described as agents responsible for PI in CAPD. PI due to Geotrichum has also been reported. We found one case in 1987 [9]and another in Mexico in 2018 [4].

In Senegal, the incidence of PI is 1.92 person-years [10]and the only fungal species found so far has been Candida albicans. We report here the case of a patient from our unit in Dakar who presented with a PI due to Geotrichum spp.

This was a 54-year-old patient who had been in CAPD for 9 months, and whose initial nephropathy was benign nephroangiosclerosis, which had been discovered 2 years prior. In her antecedents, we noted hypertensive heart disease under perindopril 10mg/d. On July 25, 2019, she presented with acute, intense abdominal pain without vomiting or diarrhea. On examination, her blood pressure was 160/80 mmHg and her temperature was 36.7°C. Her catheter exit site was clean and the drainage fluid cloudy. Her abdomen was distended, tender with defense on palpation.

The diagnosis of PI was confirmed by cytology of the peritoneal fluid, which was 2620 leukocytes/mm3 with neutrophil predominance (85%). A probabilistic antibiotic therapy based on ceftriaxone 1g/24h intraperitoneally associated with oral ciprofloxacin 500mg/24h was started. The initial evolution was marked by a decrease in the number of leukocytes in the liquid after 72 hours of treatment (L= 2000 /mm3). However, the drainage fluid was still cloudy, and the patient’s abdominal pain persisted. Bacteriological culture was negative. After 7 days of treatment, a new cytology performed counted 2500 leukocytes/mm3, still predominantly neutrophilic (70%). A new culture of the drainage liquid intended to locate opportunistic germs, a parasitological and mycological examination were requested. Mycological examination had isolated Geotrichum spp. A treatment based on oral fluconazole (200mg in the loading dose, then 100mg/d) was administered and the PD catheter was removed after 5 days. The patient was transferred to hemodialysis. After 2 hemodialysis sessions, she died in cardiogenic shock.

Geotrichum spp. are fungi belonging to the phylum Ascomycota, class Hemiascomycetes, order Saccharomycetales, family Dipodascaceae [11];[12]. Currently, three species of Geotrichum have been described as human pathogens: G. candidum, G. capitatum and G. clavatum [11];[13]. They are macroscopically identical to each other, and only the analysis of their microscopic and physiological characters makes it possible to differentiate the species. They are cosmopolitan filamentous yeasts usually present in soil, manure, fruits and dairy products, especially cheeses [16]. In humans, Geotrichum can be most often isolated in the digestive tract, and sometimes in the respiratory tract and skin [13];[14]. These are commensal species that can become pathogenic in certain circumstances, particularly in PD. Two cases of Geotrichum PI similar to our case have been described (1987; 2018) [9];[4]. If in our case it was a primary infection with Geotrichum spp, in the Mexican one [4]it was instead a recurrence of Geotrichum candidum after 2 months with a history of bacterial PI. All these cases had been in CAPD for a few months and had hypertension as a comorbidity.

The risk factors that generally predispose patients to the development of fungal PI are long-term antibiotic therapy, recent episodes of bacterial peritoneal infection, extra-peritoneal Candida infection, immunosuppression, hospitalization, prolonged stays in PD with the same peritoneal catheter and advanced age [15];[3];. None of these risk factors was found in our case, which suggests that the infection was caused by other, unknown factors or was linked to manipulations at home during bag changes.

The clinical manifestations of fungal PI are similar to bacterial ones, and the diagnosis should be considered in the event of a negative culture and the persistence of cloudy dialysis fluid and symptoms despite antibiotic treatment [4]. In our clinical case, a fungal PI was suspected in view of the persistence of the symptoms after 7 days of antibiotic therapy.

The identification of the liquid drainage by mycological examination is the most important data to confirm the diagnosis and start an appropriate treatment. In the literature, the results of this antifungal treatment are variable. Amphotericin B, fluorocytosis, ketoconazole, miconazole, econazole, fluconazole, and more recently posaconazole and voriconazole are the most commonly used antifungals. Fluconazole has some advantages over other antifungals. Its bioavailability in the peritoneal cavity when administered orally or intravenously and good tolerance of it are the main ones [4]. According to the latest update of the ISPD recommendations [17], in addition to antifungal treatment, which must be carried out for at least 14 days and sometimes beyond 4 weeks, early catheter removal remains the cornerstone of the treatment of fungal PI. In the case of our patient, the catheter was removed after 5 days of antifungal treatment.

It should be noted that the ideal antifungal treatment has not yet been identified. The appropriate dosage, the routes of administration or the duration of the treatment have not been established, though it is agreed that treatment should last at least two weeks. Prophylaxis with fluconazole (100 mg/day), ketoconazole (200 mg/day) or nystatin has been shown to be effective in reducing the incidence of fungal PI [4].

In this case, the patient died of cardiogenic shock following decompensation of her heart disease. This often unfavorable evolution has been reported several times in the literature [2]. Nevertheless, the mortality rate in the world remains variable, ranging from 5 to 40% [2]. It is higher in patients with oligoanuria [18]and in those whose peritoneal catheters were not removed quickly once infections were diagnosed [1];[2]. In a study by Wang et al.[19], catheters were removed in 83% of cases of fungal PI after an average delay of 7 days, and the mortality rate was 44.3%. In another study, PD catheters were removed in all patients at diagnosis, and the mortality rate was only 20% [18]. The delay in diagnosis and management could explain the unfavorable evolution in our patient.

Fungal peritonitis due to Geotrichum remains very rare in the literature, and this case was a first in our center. This experience should prompt clinicians to always consider it in the face of persistent signs of PI despite appropriate antibiotic therapy.