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Grossly Visible Fungal Colonization of a Tenckhoff Catheter a Case Report and Literature Review

Colonization of the Tenckhoff catheter with fungal organisms presents usually as peritonitis. The infection in the majority of these cases is due to Candida species (1). We present here acase of fungal colonization of a Tenckhoff catheter and transfer set tubing, in which the main presentation was visible particles lining the inner wall of the tubing. A 59 year old man with diabetes mellitus and chronic renal fa ilure secondary to polycystic kidney disease reached end-stage renal disease in July 1987. After a short period of hemodialysis, a Tenckhoff catheter was placed and continuous cyclic peritoneal dialysis started. In July 1988 he developed peritonitis due to Eikenella corrodens resistant to therapy and necessitating the removal of his catheter. A new Tenckhoff catheter was placed after two weeks of hemodialysis. His next episode ofperitonitis was one year later when his dialysate grew Staphylococcus epidermidis. He responded to a course of intraperitoneal vancomycin. In October 1989 he presented with cloudy dialysate. Multiple, grayish, round, 1-3 mm foreign particles were seen lining his transfer set tubing and Tenckhoff catheter. He was afebrile, the abdomen was unremarkable, and no signs of tunnel or exit site infection were noted. There were 524 WBC/mm3 of dialysate (56% segmented neutrophils, 18% lymphocytes, 18% monocytes and 8% eosinophils). The transfer set tubing was changed; dialysate and samples of the particles in the tubing were sent for bacterial, fungal and mycobacterial cultures. Vancomycin and gentamicin intraperitoneally were started. Forty eight hours later the dialysate became clear, the fluid culture obtained earlier grew Staphylacaccus epidermidis, and gentamicin was stopped. One week after the initial presentation, culture of the foreign particles yielded a filamentous fungus. The particles lining the Tenckhoff catheter remained unchanged. The catheter was removed, and no further particles were seen proximal to the exit site. The patient was hemodialyzed using subclavian temporary access. A course of250 mg of intravenous amphotericin B was given, and two weeks later a new Tenckhoff catheter was placed and CAPD resumed without problems. A sample of the particles was obtained from the tubing on a sterile swab. Within 3 days, culture yielded dark brown filamentous colonies. Slide cul ture showed dark brown conidiophores with multicelled poroconidia which formed laterally in a basipetal manner, indicative of Helminthasparium species (2). Scanning electron microscopy of particles from the Tenckhoff catheter showed septate hyphae with white blood cells attached. No spores were noted (Figure lA, IB). In areas where no particles were visible scanning electron microscopy showed no fun gal elements. Upon reviewing the literature we found very few similar cases reported (3-5). These are summarized in the Table 1. Helminthasparium is a mold of the family Dematiaceae. It is mainly a plant pathogen and has been only rarely reported to cause human disease (6). As far as we know, it has not been previously reported as a cause of peritonitis or catheter-related infection in chronic ambulatory peritoneal dialysis. The high prevalence of plant pathogens in cases in which fungal colonies are seen in the tubing is striking. It is possible that since these organisms are weak pathogens, they can grow on the tubing to the extent of forming large colonies and yet not cause peritonitis. True pathogens, on the other hand, cause peritonitis quickly and treatment (antibiotics and or catheter removal) is rendered before the organisms have time to grow on the catheter and form large colonies.