Can Cryptococcus Cause Peritonitis or Peritoneal Involvement?
Yes, Cryptococcus can definitively cause peritonitis and peritoneal involvement, though it is rare and typically occurs as part of disseminated infection in immunocompromised patients. 1
Mechanism and Clinical Context
Cryptococcal peritonitis represents disseminated disease rather than isolated infection. The Infectious Diseases Society of America explicitly states that cryptococcal infection can involve any body site following dissemination, specifically listing the peritoneum among affected structures. 1
High-Risk Populations
Cryptococcal peritonitis occurs primarily in three clinical scenarios:
- Peritoneal dialysis patients with indwelling catheters, where the catheter serves as a portal of entry 2, 3, 4
- Cirrhotic patients with ascites, where spontaneous cryptococcal peritonitis can develop, often with concurrent fungemia 5, 6
- Immunocompromised hosts on immunosuppressive therapy (corticosteroids, azathioprine) or with underlying conditions like diabetes mellitus 2, 4
Treatment Approach
For cryptococcal peritonitis, treatment must address both the peritoneal infection and the high likelihood of disseminated disease, particularly CNS involvement. 1
Mandatory Initial Steps
- Rule out CNS disease immediately through lumbar puncture and cerebrospinal fluid analysis, as cryptococcal meningitis frequently coexists with peritoneal involvement 2, 4, 5
- Obtain cryptococcal antigen titers from blood and ascitic fluid to assess fungal burden 2
- Culture ascitic fluid, blood, urine, and CSF to determine extent of dissemination 4, 5
Definitive Management
Treat as disseminated/CNS disease with amphotericin B deoxycholate or liposomal amphotericin B, with or without flucytosine. 1 This recommendation applies because:
- Cryptococcal peritonitis represents disseminated infection (involvement of at least 2 noncontiguous sites) 1
- The mortality risk is substantial, with case reports documenting death despite treatment 4, 5
For peritoneal dialysis patients specifically, remove the dialysis catheter in addition to systemic antifungal therapy. 2, 3, 4 Catheter removal is essential for eradicating infection, similar to management principles for Aspergillus peritonitis in dialysis patients. 1
Duration and Follow-up
- Continue therapy as for CNS disease given the high likelihood of meningeal involvement 1
- Monitor serial cryptococcal antigen titers to assess treatment response 2
- Investigate for sanctuary sites including prostate, which may harbor persistent infection 1
Critical Pitfalls to Avoid
Do not treat cryptococcal peritonitis as isolated peritoneal infection. The presence of peritoneal involvement mandates evaluation for disseminated disease, particularly CNS infection, which was documented in multiple case reports even when not initially suspected. 2, 4, 5
Do not use fluconazole monotherapy initially. While fluconazole (400 mg daily for 6-12 months) may be considered for single-site infection without immunosuppressive risk factors after ruling out CNS disease and fungemia, 1 cryptococcal peritonitis typically indicates disseminated infection requiring amphotericin-based induction therapy. One patient with cirrhosis survived with fluconazole treatment, but this was after early diagnosis and likely represents an exception rather than standard care. 6
In cirrhotic patients with ascites, maintain high clinical suspicion for Cryptococcus as a cause of spontaneous peritonitis, particularly when standard bacterial cultures are negative or when patients fail to respond to antibacterial therapy. 5, 6 This differs from typical spontaneous bacterial peritonitis, which is usually monomicrobial and caused by gram-negative bacteria like E. coli. 7, 8