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Diaporthe and Blastobotrys fungal peritonitis in returned travellers receiving peritoneal dialysis

Fungal peritonitis (FP) is a relatively uncommon but serious complication for patients on peritoneal dialysis (PD), with high rates of hospitalization, catheter removal, transfer to haemodialysis and death. Non-Candida FP may be increased in tropical climates, with reports from Australia describing an incidence of up to 32%, compared to North America and the United Kingdom where this represents less than 10% of cases. At our centre, we recently encountered two cases of non-Candida FP caused by atypical moulds in returned travellers. Both patients were diabetic and required catheter removal and permanent transition to haemodialysis. The first patient was a 76-year-old female who developed bacterial peritonitis while on vacation in Panama, who had unresolving symptoms on return to Canada. She was noted to have black growth within her catheter lumen and subsequently cultured Diaporthe fungus from both her PD effluent and catheter tip. The second patient was a 70-year-old male who upon returning from a trip to the Philippines presented with cloudy effluent and symptoms of peritonitis. His PD effluent cultured Blastobotrys proliferans. Diaporthe species is a rare pathogen in humans, with only single cases of osteomyelitis, keratitis and cutaneous infection described in association with immunosuppression. We believe this is the first reported case of Diaporthe-related FP. Blastobotrys proliferans is also rarely associated with human infection, with only one previous case of PD peritonitis due to Blastobotrys reported in 2007 in New Caledonia. We believe that the incidence and range of organisms causing FP could potentially increase due to improved access to and affordability of global travel for patients on PD. Social and environmental factors may predispose patients to acquiring FP and clinicians should educate patients on how to reduce infection risk when travelling, focusing on the correct storage of PD solutions and assessment of anticipated living arrangements. It is important that clinicians, microbiologists and laboratory staff are vigilant in considering non-Candida FP, particularly in returned travellers from tropical regions, as these fungi can be difficult to isolate and may take weeks to culture. Furthermore, it is vital to recognize the potential pathogenicity of moulds in causing peritonitis and not to dismiss them as environmental contaminants. Identification and reporting of moulds which may have previously been considered non-pathogenic will allow better understanding of this expanding and important entity of infections.