CORRESPONDENCE
6 PDI
Hendriksen A, Monnens LAH, Schroder CH. Local fibrin-
olytic therapy with urokinase for peritoneal dialysis cath-
eter obstruction in children. Perit Dial Int 2002; 22:84–6.
3. Yilmazlar T, Kirdak T, Bilgin S, Yavuz M, Yurtkuran M.
Laparoscopic findings of peritoneal dialysis catheter mal-
function and management outcomes. Pert Dial Int 2006;
26:374–9.
4. Cacho CP, Tessman MJ, Newman LN, Friedlander MA. In-
flow obstruction due to kinking of coiled catheters dur-
ing placement. Perit Dial Int 2007; 27:276–8.
Case Report and Review: Is the Tendency
for Curvularia Tubular Obstruction
Significant in Pathogenesis?
Editor:
Curvularia is a phytopathogen that causes turf blight
in grass and rarely any human infection. It was reported
to cause tubular obstruction with peritonitis in three
previous case reports (1–3), tubular obstruction with-
out peritonitis in three case reports (4–6), and perito-
nitis without tubular obstruction in two reports (7,8).
Traditional risk factors have been considered to be
(1) previous bacterial infection treated with antibiotics,
(2) exposure to soil, (3) immunosuppression, and
(4) bowel perforation (4,7,9). We report a case of
Curvularia causing tubular obstruction without perito-
nitis in a patient with no risk factors and suggest that
the risk factor may be the dialysis tubing itself.
A 53-year-old woman with end-stage renal disease
secondary to hypertension, who spent most of her daily
routine indoors with her aging grandmother, had been
treated with continuous cyclic peritoneal dialysis (12 L
total volume, with 2.5 L for 10 hours, and a last bag of
2.0 L), using a silicone Tenckhoff catheter (Quinton, Se-
attle, Washington, USA), for 4 years with no history of
peritonitis. She noticed black spots in her peritoneal di-
alysis catheter for 3 weeks, followed by difficulty in
drainage. Examination revealed a thick black material
growing in the silicone tubing, which proved on culture
to be pure growth of Curvularia.
The most common procedure for measuring the preva-
lence of Curvularia’s ubiquitous spores involves the use
of a microscope slide coated with silicone (8). Although
its spores are widespread in warm moist climates, it rarely
causes human infections; however, it has become noto-
rious for other invasions. Investigators have noted that
Curvularia is one of the micro-organisms that colonize
stone churches containing silicon (10) and silicone volt-
age insulators (11). In humans, it has been implicated
in outbreaks in silicone breast implants (12) and silicone
678
NOVEMBER 2008 – VOL. 28, NO.
intraocular lenses (13) and silicone contact lenses (14).
Finally, this is the tenth case report of invasion of a sili-
cone peritoneal dialysis catheter. Therefore, we postu-
late that the predilection for organic silicone or inorganic
silicon substrate may not be coincidental.
Silicon is the second most abundant element in soil
after oxygen, and plays a large role in growth, mechani-
cal strength, and resistance to disease in plants (15).
Grasses are known to accumulate silicon. The incorpora-
tion of Si promoted the evolution of tall grasses by cre-
ating stronger cell walls that had a greater ability to
capture energy at low energy cost. A related phytopatho-
genic fungus, Fusarium, is known to accumulate Si for
use in nanotechnology (16). Low levels of Si enhance
growth of both Curvularia and Fusarium in the presence
of an alkaline medium such as fresh peritoneal dialysate
(17), which might explain the preference of Curvularia
Downloaded from www.pdiconnect.com by on January 24, 2011
and Fusarium (18) to colonize organic Si in silicone
[(R2SiO)n] rather than to produce active human infec-
tions. Similarly, the alkaline pH of dialysate might also
explain why, despite the ubiquitous nature of Curvularia
spores, there has never been a report of a Curvularia exit-
site infection or tunnel invasion, or even growth on the
outside wall of a catheter, but always invasion of the lu-
minal side with tubular obstruction.
There may also be other factors involved, both bio-
chemical and immune. The susceptibility of xenobiotic
materials to biodegradation by micro-organisms is de-
pendent on the many properties of the polymer, such as
molecular orientation, crystallinity, cross-linking, and
the chemical groups present in the molecular chains that
determine accessibility to degrading enzyme systems
(19). Perhaps the salt in dialysate or the saline filling
silicone breast implants allows that chemistry to de-
velop. Similarly, since hydoxylated silica gel is known to
trap polar organic molecules, some speculate that bio-
logic systems evolved polysaccharides for binding to
silica gel as an evolutionary prelude to the progression
from inorganic to carbon-based life forms (20,21). Al-
ternatively, since Curvularia is necrotrophic, it may pre-
fer the catheter as a host, which it does not need to kill.
C.J. Diskin*
T.J. Stokes
L.M. Dansby
L. Radcliff
T.B. Carter
Auburn University
Opelika, Alabama, USA
*e-mail: hndt512@bellsouth.net
PDI NOVEMBER 2008 – VOL. 28, NO. 6
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Aureobasidium pullulans Peritonitis: Case
Report and Review of the Literature
Editor:
Fungal peritonitis is a rare but serious complication
of continuous ambulatory peritoneal dialysis (CAPD)
(1,2). We report a case of peritonitis due to Aureo-
basidium pullulans, a rare fungal pathogen, and review
previous publications.
A 37-year-old Japanese male with end-stage renal
failure due to chronic glomerulonephritis started CAPD
via a double-cuffed Tenckhoff catheter in May 2006. He
was using a double-bag system with manual con-
nectology. In April 2007 he developed his first episode
of peritonitis, presenting with a low grade fever, abdomi-
nal pain, and cloudy dialysate, and visited our outpatient
department 2 weeks after the onset of his symptoms.
Physical examination revealed abdominal rebound ten-
derness and muscular defense. Drained dialysate was
cloudy with an elevated cell count of 1900 cells/mm3
(71% polymorphonuclear leukocytes, 6% lymphocytes,
3.5% eosinophils, and 19.5% unclassified cells). He was
admitted to the hospital and empirical therapy for peri-
tonitis with cefazolin and ceftazidime was started, but
no improvement in clinical symptoms was observed. Two
days later, his peritoneal fluid cultures grew black fun-
gal colonies. We identified this fungus as the pathogen
of the peritonitis, not as a contaminant, because these
colonies were observed in two consecutive examinations.
With the diagnosis of fungal peritonitis, the peritoneal
catheter was removed immediately, as is recommended
679