Case 93 -- Peritonitis

Contributed by Michael Torbenson, MD., John Sheaffer, MD., Robert Macauley, MD., John
Anhalt, MD., PhD. and William Pascule, ScD.
Published on line in February 1997


PATIENT HISTORY:



A 26 year old female had a 13 year history of poorly controlled insulin-dependent diabetes
mellitus that led to renal failure and blindness. She required peritoneal dialysis which was
complicated by multiple infections of the peritoneal catheter. She also was obese and
hypertensive. She presented to the hospital with abdominal cellulitis, fevers, and chills. On
physical examination, she had ulcerated areas of skin underneath the pannus. She underwent
debridement of the wound and was diagnosed with necrotizing fascitis. Despite antibiotic
treatment and wound care, the wound was not healing (Images 01) and required a second
debridement several weeks later. Her peritoneal dialysate was also noted to be cloudy and
cultures were obtained which were positive for Enterococcus faecalis and a wet mount
preperationan also showed unusual organism (Image 02, Image 03). Because of her continued
sepsis and poor prognosis, her family and team of physicians followed the patent's previously
expressed wishes and proceeded with comfort measures only. The patient was transferred to a
hospital nearer her home and she died several days later.
Laboratory Identification -- Peritonitis


LABORATORY IDENTIFICATION:







Prototheca grows easily on glucose containing media and is typically grown on sabouraud's agar,
but it will not grow on media that contain cycloheximide. The colonies (Images 04, Image 05)
appear yeast-like and are smooth, moist, and white to cream in color. The algae grows best at 30
C and growth is inhibited at 37 C (1,2). Prototheca are unicellular organisms that are typically
round to oval and 8-16 um in diameter, though they can range from 3 to 30 um depending on the
species and the degree of maturation. The organisms reproduce by a mother cell undergoing
internal cleavage. This results in the internal accumulation of smaller endospores surrounded by
the wall (or theca) of the mother cell. The mother cell then bursts, releasing the endospores and
the cycle is repeated. The endospores are 4 to 5 um in diameter and can number from two to 50
(2). These endospores give Prototheca its characteristic "cart wheel" appearance of a round
structure with internal septations. The larger forms can have very thick walls. The algae are
basophilic and have been reported to be Gram positive (2), though in this case the theca are
Gram negative and the endospores Gram positive (Image 06, Image 07). PAS staining highlights
the starch granules which are occasionally present.
Prototheca can be identified by its colony morphology in conjunction with its characteristic
microscopic appearance when examined via wet mount or a lactol-phenol cotton blue preparation
(image 08, Image 09). Speciation, however, requires further analysis and relies on diameter,
assimilation of various sugars and the presence or absence of an external capsule (1,3,4).
Commercial strips (image 10) are available that can also be useful in species identification.
Using an API 20C, this case was speciated to P. wickerhamii (5).