Rare Fungal Infection Triggers Peritonitis in Dialysis Patient: First Report of Acremonium Sclerotigenum Involvement

The case involved a 79-year-old male undergoing maintenance peritoneal dialysis for end-stage renal disease. The patient presented with persistent lower abdominal pain, diarrhea, and cloudy dialysate—common symptoms of peritonitis. Initial lab findings revealed an elevated white blood cell count in the peritoneal fluid, raising suspicion of infection. Although the patient had not received antibiotics before admission, empiric antibacterial treatment was initiated using intravenous ceftriaxone and vancomycin added to the dialysis fluid.

When the condition failed to improve after five days, antifungal therapy with voriconazole was introduced. Cultures obtained on the day of admission later confirmed the presence of Acremonium sclerotigenum, a saprophytic fungus commonly found in soil and plants. This rare pathogen is known to cause superficial infections, such as onychomycosis, but is an unusual culprit in invasive infections like peritonitis.

Following the identification of the fungus, the peritoneal dialysis catheter was removed, and the patient was transitioned to hemodialysis via a semi-permanent neck catheter. The voriconazole dose was carefully adjusted based on therapeutic drug monitoring, and the antifungal therapy was continued for four weeks. Post-treatment follow-up nine months later confirmed that the patient remained asymptomatic and continued with hemodialysis without complications.

The case emphasizes the critical need for early diagnosis and aggressive treatment of fungal peritonitis, particularly given the high mortality associated with delayed catheter removal. According to the 2022 guidelines by the International Society for Peritoneal Dialysis (ISPD), immediate catheter removal and targeted antifungal therapy are key to improving outcomes in such cases.

Though Acremonium sclerotigenum is environmentally widespread, its identification in PDAP is unprecedented. The authors note the challenge of treating infections caused by this species due to its resistance to common antifungals like fluconazole and flucytosine. Voriconazole and posaconazole appear to be more effective options based on current evidence.

The case contributes to the growing body of literature on fungal peritonitis. It emphasizes the role of environmental fungi as emerging opportunistic pathogens in immunocompromised patients. It also highlights the need for further research and clear treatment protocols for rare fungal infections in peritoneal dialysis patients.

Reference:

Wang, J., Cheng, Y., Yan, Q. et al. Peritoneal dialysis–associated peritonitis caused by acremonium sclerotigenum: a case report. BMC Nephrol 26, 264 (2025). https://doi.org/10.1186/s12882-024-03884-5