Peritoneal dialysis complicated by Bipolaris hawaiiensis peritonitis: successful therapy with catheter removal and oral itraconazol without the use of amphotericin-B.

Fungi classified in the genera Bipolaris are an uncommon source of infection in human diseases. It is also a rare source of peritonitis in peritoneal dialysis (PD) patients. All cases of Bipolaris peritonitis reported in the United States have occurred in the southern states. This form of peritonitis appears to have a good prognosis, with cure achieved only after removal of the peritoneal dialysis catheter and antifungal therapy. Systemic or intraperitoneal amphotericin-B with or without oral ketoconazole has been used in all previously reported cases. However, the role of antifungal therapy is unclear. We report a case of Bipolaris hawaiiensis peritonitis in a 73-year-old female on continuous cyclic peritoneal dialysis (CCPD) for 10 months who presented with a nonfunctioning peritoneal catheter. The catheter had characteristic dark gray particles, each composing a fungal ball within the lumen of the catheter. Microscopic examination confirmed the organism attached to the inner wall of the catheter. The patient achieved cure without using either amphotericin-B or ketoconazole. She was treated with removal of the catheter and a 2-week course of oral itraconazole 100 mg twice daily. A new catheter was placed after 1 month and the patient continued to do well on CCPD 12 months later with no evidence of recurrent infection. We conclude that (1) itraconazole can effect cure following removal of the catheter without using amphotericin-B or ketoconazole; (2) peritoneal dialysis can be safely reinstituted after itraconazole therapy for this uncommon fungal infection, and (3) itraconazole therapy allows for out-patient treatment of B. hawaiiensis peritonitis in peritoneal dialysis patients.