Paecilomyces variotii in Peritoneal Dialysate - Journal of Clinical ...

JOURNAL OF CLINICAL MICROBIOLOGY, Sept. 1993, p. 2392-2395

Vol. 31, No. 9

0095-1137/93/092392-04$02.00/0 Copyright © 1993, American Society for Microbiology

Paecilomyces variotii in Peritoneal Dialysate ANTONIA MARZEC,1* LEON G. HERON,2 ROBERT C. PRITCHARD,3 REGINALD H. BUTCHER,' HARLEY R. POWELL,4 ALEX P. S. DISNEY,5 AND FREDERICK A. TOSOLINI'

Department of Medical Microbiology, Austin Hospital, 1 and Renal Unit, Royal Children's Hospital,4 Melbourne, Victoria, Microbiology Department, Prince of Wales Hospital, Randwickl New South Wales,2 Microbiology Department, Royal North Shore Hospital, St. Leonards, New South Wales,3 and Queen Elizabeth Hospital, Woodville South, South Australia, Australia 5

Received 17 February 1993/Returned for modification 17 April 1993/Accepted 11 June 1993

Four cases of peritonitis caused by the filamentous fungus Paecilomyces variotii in patients on continuous ambulatory peritoneal dialysis are reported. Removal of the Tenckhoff catheter and antifungal chemotherapy led to resolution of symptoms in all cases. Possible contaminating events are discussed, and reported infections with P. variotii are reviewed.

Fungal peritonitis in patients on peritoneal dialysis is a serious complication than bacterial peritonitis. About 75% of reported cases have been caused by yeasts of Candida species. Less frequently, infections with a variety of other yeasts and filamentous fungi have been reported. Since the introduction of continuous ambulatory peritoneal dialysis (CAPD) in 1976 (25), peritonitis has remained the most important complication. The reported incidence of peritonitis was as high as 6.3 episodes per patient-year (29) in the early years of experience with peritoneal dialysis. With further development in methods for connection of dialysate bags and with greater staff experience, the incidence of peritonitis has now decreased to less than 1.3 episodes per patient-year (24, 30). Most series report that about 7% of CAPD-related peritonitis episodes have a fungal etiology (3, 5, 6, 17, 24, 26, 28). Death from fungal peritonitis occurred in 12 to 44% of reported patients (6, 9, 15, 24, 28). This is in contrast to a mortality rate of 0.6 to 3% for patients with bacterial peritonitis (18, 37). Fungal peritonitis was, after cardiovascular disease, the second most common event associated with death in two Australian studies of patients on CAPD (24, 41). Of 40 deaths reported in those two studies, 15 were associated with cardiovascular disease, 7 were associated with fungal peritonitis, and 4 were due to bacterial peritonitis. We report here four cases of CAPD-related peritonitis caused by Paecilomyces variotii Bainier. more

CASE REPORTS

Patient 1. A 12-year-old boy with end-stage renal failure had been on CAPD since August 1988. In February 1990, he was referred to the Royal Children's Hospital, Melbourne, Victoria, Australia, with a history of intermittent cloudy peritoneal dialysis (PD) fluid. Cultures of the fluid had been carried out in Hobart, Tasmania, Australia, but had not yielded any microorganisms. The patient had been treated with ceftazidime in the dialysate, and during this time he had mild abdominal pain and some suprapubic discomfort. On admission, he was apyrexial and had no frequency or dysuria. P. variotii was grown from each of five bags of PD fluid from the patient. Antifungal susceptibility testing was not *

Corresponding author.

performed. He was treated with amphotericin B, 5 mg/liter of PD fluid, for 10 days, but the infection failed to clear. The Tenckhoff catheter was then removed and hemodialysis was commenced. The symptoms of peritonitis rapidly settled without further antifungal therapy and he remained on hemodialysis until a renal transplant from his mother in June 1990. No fungus was isolated from the tip of the dialysis catheter. Patient 2. A 60-year-old woman with longstanding renal failure had been using CAPD for 4 years. Following several episodes of abdominal pain in May 1990, a Staphylococcus species was cultured from the cloudy PD fluid. She received flucloxacillin and gentamicin and subsequently vancomycin and gentamicin following isolation of Staphylococcus epidermidis and a Pseudomonas species. After fungal growth was seen on a culture from one of the dialysate bags, amphotericin B was introduced and was continued for 5 days. At the time of transfer from Darwin, Northern Territory, Australia, to the Queen Elizabeth Hospital, Adelaide, Australia, the identity of the fungus had not been established. Upon arrival in Adelaide, the patient was afebrile and the peritoneal fluid showed a moderate number of polymorphs but no fungal elements and no bacteria. Vancomycin was continued for the next week, during which she remained afebrile. Following a report of identification of the fungus as P. variotii, which was isolated from three PD bags, the Tenckhoff catheter was removed. Amphotericin B was given intravenously and was continued for 4 weeks for a total of 1,480 mg. A biopsy specimen taken from a 5-cm white indurated area in the peritoneal wall adjacent to the bladder revealed fungal elements. She did not return to CAPD but continued on hemodialysis. The isolate of P. variotii was reportedly susceptible to amphotericin B, nystatin, natamycin, clotrimazole, miconazole, ketoconazole, flucytosine, and itraconazole but was resistant to fluconazole. Patient 3. A 56-year-old woman with chronic renal failure had been using CAPD for 4 years. Following a below-knee amputation of the leg in Melbourne in June 1990, she developed abdominal pain and cloudy PD fluid. She was treated with single doses of tobramycin and flucloxacillin intramuscularly; this was followed by treatment with flucloxacillin, 125 mg/liter, in the PD fluid. After an initial improvement, the packs became cloudy again and treatment was changed to cephalothin, 250 mg/liter of PD fluid, plus a further dose of tobramycin intravenously. A Micrococcus sp. was isolated from the PD fluid, and treatment was 2392

VOL. 31, 1993

changed to vancomycin, 750 mg/liter of PD fluid. The patient became increasingly unwell. Three specimens of dialysis fluid had leukocyte counts of >500,000/ml. Hyphal elements were observed macroscopically in one of the PD specimens and microscopically in the other two specimens, and P. variotii was isolated from all three specimens. The organism was susceptible to amphotericin B, flucytosine, ketoconazole, and itraconazole but was resistant to miconazole and fluconazole. The Tenckhoff catheter was removed, and culture of the catheter tip yielded P. variotii. The patient was treated with ketoconazole, 400 mg orally three times daily for 10 days, and was subsequently discharged from the hospital, having been transferred to hemodialysis. Patient 4. A 39-year-old Australian aboriginal man with chronic renal failure secondary to hypertension and diabetes had been using CAPD since May 1989. In January 1990 and May 1990, he suffered episodes of bacterial peritonitis. In June 1990, he presented to Prince Henry Hospital, Sydney, New South Wales, Australia, because the Tenckhoff catheter was draining poorly and he had become overhydrated. At 4 days after admission, he developed peritonitis caused by Streptococcus mitis and Acinetobacter sp. Treatment with imipenem intravenously and vancomycin, 10 mg/liter in the PD fluid, resulted in resolution of most symptoms and clearing of the dialysate, but intermittent abdominal pain continued. In July 1990, one colony of P. variotii was isolated from a specimen of PD, although the fluid did not contain leukocytes or erythrocytes. The fungus was not isolated from four subsequent specimens. Clinical peritonitis then recurred and a Proteus sp. was isolated from the PD fluid. Two further specimens grew P. variotii (approximately 20 CFU/ml). The organism was susceptible to amphotericin B, flucytosine, ketoconazole, and itraconazole but was resistant to miconazole and fluconazole. The patient was treated orally with ketoconazole, 200 mg daily, the Tenckhoff catheter was removed, and hemodialysis was commenced. The patient's abdominal symptoms resolved within a week, and he has remained on hemodialysis. The patient remains well on hemodialysis.

MATERIAILS AND METHODS After the needle port of the dialysis bags was disinfected with 70% alcohol, samples of PD effluent were aseptically collected with a sterile syringe and needle. A leukocyte count was performed on the PD fluid by using a hemocytometer. A 25-ml volume of PD fluid was centrifuged, from the pellet a smear was prepared for Gram staining, and blood agar plates were inoculated and incubated aerobically and anaerobically for 5 days. When a fungal etiology was suspected, the pellet was also cultured on brain heart infusion agar, which was incubated at 35°C for 30 days, and on Sabouraud dextrose agar, which was incubated at 26°C for 30 days. A KOH wet mount was also prepared from the pellet for microscopic examination. Saponin lysis of dialysis fluid prior to culturing, in order to increase the microbial yield (39), was routinely carried out in one of the laboratories involved. After initial identification in the laboratory where the

organism was isolated, confirmation of the identity of the isolate and antifungal susceptibility tests were performed at the Royal North, Shore Hospital, Sydney, New South Wales (patients 3 and 4) or at the Women's and Children's Hospital, North Adelaide, South Australia (patient 2). The organisms isolated from patients 2, 3, and 4 were tested for

P. VARIOTII IN PERITONEAL DIALYSATE

2393

susceptibility by the disk diffusion technique by using Neosensitabs (Roscoe Diagnostica, Taastrup, Denmark) (44). For patient 2, the procedure was varied as follows. A standardized light inoculum of the isolate to be tested was streaked onto plates containing either complex Casitone medium (14) or, in the case of flucytosine testing, supplemented yeast nitrogen agar medium (33). RESULTS AND DISCUSSION The genus Paecilomyces is similar to the genus Penicillium (20) but is distinguished by the lack of green-colored colonies and by basally swollen phialides tapering toward their apex and bearing long, tangled, or divergent chains of smooth-walled, single-celled conidia (31). The phialides are borne in a penicillate arrangement or in verticils, and their necks are often bent away from the main axis. So far, only a few species have been connected to teleomorphs, and these are in the order Eurotiales, e.g., the genera Byssochlamys, Thermoascus, and Talaromyces, or in the order Clavicipitales, e.g., the genus Cordyceps (31). No teleomorph is known for P. variotii. This species is a common airborne fungus and is found in soil and decaying organic material. It is well known as a common spoilage organism (21) and has been found to be resistant to preservatives such as benzoic acid, propionic acid, and sorbic acid (32). Optimal growth occurs at 35°C, with a range of growth temperatures from 5 to 50°C (32). P. variotii grows rapidly, with colonies attaining a diameter of 8 cm within 14 days at 25°C on malt agar and having a sweet odor (31). Colonies on Sabouraud dextrose agar are powdery and yellow-brown with a raised velvety center and a brown reverse. P. variotii phialides measure approximately 12 to 20 by 2.5 to 5.0 ,um (31). Conidia are hyaline to yellow and elliptical in shape and usually measure 3.2 to 5.0 by 2.0 to 4.0 p.m, but they are variable in shape and size and may be as large as 15 by 5.0 pum (31). Factors influencing this variation include the age of the colony and the extent of sporulation. Smaller conidia are produced in abundantly sporulating strains, whereas larger conidia can be observed under less suitable conditions (31). Chlamydospores are usually present in old cultures, singly or in short chains, mostly brown with smooth to slightly roughened walls (31). As defined by Ajello (1), hyalohyphomycosis is an opportunistic infection involving hyphomycetes, such as Paecilomyces spp., with hyaline or light-colored cell walls. In contrast, infection with opportunistic hyphomycetes having melanin in the cell wall is called phaeohyphomycosis (27). P. variotii has rarely been implicated in human infections. Reports in the medical literature have included a case of peritonitis in a patient on CAPD (7), five fatal cases of prosthetic valve endocarditis (11, 16, 19, 35, 42), a case of pyelonephritis complicating surgery for nephrolithiasis (34), a fatal infection of a ventriculoperitoneal shunt (10), two cases of sinusitis (22, 40), a lacrimal sac infection (13), and a case of pneumonitis complicating hairy cell leukemia (8). A review of human Paecilomyces species infections has been presented by Castro et al. (4). Filamentous fungi are infrequent causes of CAPD peritonitis. The four cases reported here add to an increasing recognition of P. variotii as a potential pathogen in patients undergoing CAPD. In the 4 years prior to 1990, isolates of P. variotii from five patients undergoing CAPD with peritonitis had been received at the Australian Medical Mycology Reference Laboratory, in the Department of Microbiology at the Royal North Shore Hospital. In addition, there had been

2394

MARZEC ET AL.

three isolates of P. vanotii from unused bags of PD fluid. In 1986, at the Prince of Wales Hospital, Sydney, two strains of P. variotii were isolated from fluid obtained from unused dialysate bags. Macroscopic fungal elements were noted by a patient as he prepared the dialysate for use. P. vanotii was also isolated at the Royal North Shore Hospital, Sydney, from an unused bag after macroscopic fungal elements were detected by a patient. This patient subsequently developed chronic peritonitis caused by P. vaniotii and his Tenckhoff catheter had to be removed. The four cases of P. vanotii peritonitis reported here occurred between February and July 1990 in Darwin, Hobart, Melbourne, and Sydney. In each case, the fungus was readily isolated from multiple used dialysate bags on several culture media and P. variotii was isolated during hospitalization when there had been repeated episodes of known or suspected bacterial peritonitis and repeated antibacterial treatments. Early removal of the catheter and amphotericin B administered intravenously or ketoconazole administered orally was used in successful management. It is important to distinguish among species of Paecilomyces (36), because their susceptibility patterns to antifungal agents vary. P. vanotii is susceptible to amphotericin B and flucytosine, whereas Paecilomyces lilacinus (Thom) Samson is highly resistant to these two agents (36). Reviews of treatment strategies for fungal peritonitis have been published (2, 38). However, the treatment of infections with filamentous fungi was not included. Early removal of the dialysis catheter is an important adjunct to therapy. None of the four patients described here has resumed CAPD. After an episode of bacterial peritonitis, 95% of patients are able to continue CAPD or have the technique reestablished (24), but following fungal peritonitis, no more than 35% of patients are able to continue CAPD or have the technique reestablished (6, 9, 15, 24, 28). Reestablishment of CAPD treatment may not be possible because of peritoneal adhesions, abscess formation, or progressive sclerosing peritonitis (28). The patients continue to be very susceptible to infection, and in one study (18), 50% of cases of fungal peritonitis immediately followed or were superimposed upon gram-negative bacterial peritonitis. In patients undergoing CAPD, susceptibility to infection is increased because the indwelling catheter acts as a foreign body, there is decreased phagocytic activity in the peritoneal cavity, and opsonic factors in the PD fluid are diluted and lost (12, 29). In most patients with CAPD-related peritonitis, entry of the causative organism is via contamination of the dialysis catheter or PD fluid and additives. Recognized breaks in aseptic technique are a common antecedent to peritonitis in these patients (41). Improvements in aseptic technique, reduction in the number of catheter manipulations, better connections between the Tenckhoff catheter and the dialysate bag, and the use of bacterial filters are important factors in reducing infection (23, 41). When a patient is suffering from repeated episodes of peritonitis, the illness may cause the patient to be unable to properly maintain aseptic techniques, and the use of broad-spectrum antibiotics may allow overgrowth of fungi. An attempt to find a common link between the four cases of P. variotii peritonitis by checking batch numbers and dates of manufacture of dialysate fluids used in these patients was unsuccessful. The spores of P. variotii are ubiquitous and abundant. They are likely to be present in the environment at places of manufacture, storage, and use of the bags of PD fluid. Experiments on PD fluid bags have shown a slow growth

J. CLIN. MICROBIOL.

rate from small inocula of P. vaniotii (18a), suggesting that contamination of a bag occurs at least 2 to 3 weeks before fungal elements become visible in the fluid. Shortly after the presentation of patient 4, swabs taken from wooden shelves with deteriorating paint work on which the peritoneal dialysis bags were stored grew P. variotii. Hence, an observation of fungal filaments in an unused bag of PD fluid suggests an inoculation event during manufacture or storage. Paecilomyces spp. are associated with "wood-trimmers' disease" (43), and the finding of P. vanotii on wooden storage shelves where the peritoneal dialysis bags were stored strengthens the association of P. vanotii and wood in the environment. ACKNOWLEDGMENTS We thank P. C. Taylor, Prince of Wales Hospital, Sydney, New South Wales; D. H. Ellis, Adelaide Children's Hospital, South Australia; M. R. Robertson, Senior Staff Nephrologist, The Prince Henry Hospital, Little Bay, New South Wales; and M. A. J. Williams, International Mycological Institute, Kew, Surrey, United Kingdom, for valuable help and A. McLean and P. Chester for research assistance. REFERENCES 1. Ajello, L. 1986. Hyalohyphomycosis and phaeohyphomycosis. Two global disease entities of public health importance. Eur. J. Epidemiol. 2:243-251. 2. Bayer, A. S., M. J. Blumenkrantz, J. Z. Montgomerie, J. E. Galpin, J. W. Coburn, and L. B. Guze. 1976. Candida peritonitis. Report of 22 cases and review of English literature. Am. J. Med. 61:832-840. 3. British Society for Antimicrobial Chemotherapy. 1987. Report of a working party of the British Society for Antimicrobial Chemotherapy. Diagnosis and management of peritonitis in continuous ambulatory peritoneal dialysis. Lancet i:845-849. 4. Castro, L. G. M., A. Salebian, and M. N. Sotto. 1990. Hyalohyphomycosis by Paecilomyces lilacinus in a renal transplant patient and a review of human Paecilomyces species infections. J. Med. Vet. Mycol. 28:15-26. 5. Cecchin, E., S. DeMarchi, G. Panarello, and F. Tesio. 1985. Chemotherapy and/or removal of the peritoneal catheter in the management of fungal peritonitis complicating CAPD? Nephron 40:251-252. 6. Cheng, I. K., G. X. Fang, T. M. Chan, P. C. Chan, and M. K. Chan. 1989. Fungal peritonitis complicating peritoneal dialysis: report of 27 cases and review of treatment. Q. J. Med. 71:407416. 7. Crompton, C. H., R. C. Summerbell, and M. M. Silver. 1991. Peritonitis with Paecilomyces complicating peritoneal dialysis. Pediatr. Infect. Dis. J. 10:869-871. 8. Dharmasena, F. M. C., G. S. R. Davies, and D. Catovsky. 1985. Paecilomyces variotii pneumonia complicating hairy cell leukaemia. Br. Med. J. 290:967-968. 9. Eisenberg, E. S., I. Leviton, and R. Soeiro. 1986. Fungal peritonitis in patients receiving peritoneal dialysis: experience with 11 patients and review of the literature. Rev. Infect. Dis. 8:309-321. 10. Fagerburg, R., B. Suh, H. R. Buchley, B. Lorber, and J. Karian. 1981. Cerebrospinal fluid shunt colonisation and obstruction by Paecilomyces variotii. Case report. J. Neurosurg. 54:257-260. 11. Haldane, E. V., J. L. MacDonald, W. O. Gittens, K. Yuce, and C. E. van Rooyen. 1974. Prosthetic valvular endocarditis due to the fungus Paecilomyces. Can. Med. Assoc. J. 111:963-968. 12. Harvey, D. M., K. J. Sheppard, A. G. Morgan, and J. Fletcher. 1987. Effect of dialysate fluids on phagocytosis and killing by normal neutrophils. J. Clin. Microbiol. 25:1424-1427. 13. Henig, F. E., N. Lehrer, A. Gabbay, and O. Kurz. 1973.

P. VARIOTII IN PERITONEAL DIALYSATE

VOL. 31, 1993

Paecilomycosis of the lacrimal sac. Mykosen 16:25-28. 14. Iwata, K., and H. Vanden Bossche. 1986. In vitro and in vivo evaluation of antifungal agents. Elsevier Scientific Publishers, Amsterdam. 15. Johnson, R. J., P. G. Ramsey, N. Gallagher, and S. Ahmad. 1985. Fungal peritonitis in patients on peritoneal dialysis: incidence, clinical features and prognosis. Am. J. Nephrol. 5:169175. 16. Kalish, S. B., R. Goldschmidt, C. Li, R. Knop, F. V. Cook, G. Wilner, and T. A. Victor. 1982. Infective endocarditis caused by Paecilomyces variotii. Am. J. Clin. Pathol. 78:249-252. 17. Kerr, C. M., J. R. Perfect, P. C. Craven, J. H. Jorgensen, D. J. Drutz, J. D. Shelburne, H. A. Gallis, and R. A. Gutman. 1983. Fungal peritonitis in patients on continuous ambulatory peritoneal dialysis. Ann. Intern. Med. 99:334-337. 18. Kraus, E. S., and D. A. Spector. 1983. Characteristics and sequelae of peritonitis in diabetics and non diabetics receiving chronic intermittent peritoneal dialysis. Medicine 62:52-57. 18a.Marzec, A. Unpublished data. 19. McCleelan, J. R., J. D. Hamilton, J. A. Alexander, W. G. Wolfe, and J. B. Reed. 1976. Paecilomyces varioti endocarditis on a prosthetic aortic valve. J. Thorac. Cardiovasc. Surg. 71:472475. 20. McGinnis, M. R. 1980. Laboratory handbook of medical mycology, p. 247. Academic Press, Inc., New York. 21. Onions, A. H. S., A. Allsopp, and H. 0. W. Eggins (ed.). 1981. Smith's introduction to industrial mycology, 7th ed., p. 218. Edward Arnold Ltd., London. 22. Otcenasek, M., Z. Jirousek, Z. Nozicka, and K. Mend. 1984. Paecilomycosis of the maxillary sinus. Mykosen 27:242-251. 23. Peterson, P. K., G. Matzke, and W. F. Keane. 1987. Current concepts in the management of peritonitis in patients undergoing CAPD. Rev. Infect. Dis. 9:604-612. 24. Pollock, C. A., L. S. Ibels, R. J. Caterson, J. F. Mahony, D. A. Waugh, and B. Cocksedge. 1989. Continuous ambulatory peritoneal dialysis. Eight years of experience at a single centre. Medicine 68:293-308. 25. Popovich, R. P., J. W. Moncrief, K. D. Nolph, A. J. Ghods, Z. J. Twardowski and W. K. Pyle. 1978. Continuous ambulatory peritoneal dialysis. Ann. Intern. Med. 88:449-456. 26. Prowant, B., K. Nolph, L. Ryan, Z. Twardowski, and R. Khanna. 1986. Peritonitis in continuous ambulatory peritoneal dialysis: analysis of an 8-year experience. Nephron 43:105109. 27. Rippon, J. W., R. A. Larson, D. M. Rosenthal, and J. Clayman. 1988. Disseminated cutaneous and peritoneal hyalohyphomycosis caused by Fusainum species. Three cases and review of the literature. Mycopathologia 101:105-111. 28. Rubin, J., K. Kirchner, D. Walsh, M. Green, and J. Bower. 1987. Fungal peritonitis during continuous ambulatory peritoneal dialysis: a report of 17 cases. Am. J. Kidney Dis. 10:361368. 29. Rubin, J., W. A. Rogers, H. M. Taylor, E. D. Everett, B. F. Prowant, L. V. Fruto, and K. D. Nolph. 1980. Peritonitis during

30.

31.

32. 33.

34. 35. 36.

37. 38.

39.

40.

41.

42. 43.

44.

2395

continuous ambulatory peritoneal dialysis. Ann. Intern. Med. 92:7-13. Saklayen, M. G. 1990. CAPD peritonitis. Med. Clin. N. Am. 74:997-1010. Samson, R. A. 1974. Paecilomyces and some allied hyphomycetes. Studies in mycology, no. 6, p. 14-19. Centraalbureau voor Schimmelculture, Baarn, The Netherlands. Samson, R. A., and E. S. Van Reenen-Hoekstra. 1988. Introduction to food borne fungi, 3rd ed., p. 112. Centraalbureau voor Schimmelculture, Baarn, The Netherlands. Shadomy, S., A. Espinel-Ingroff, and R. Y. Cartwright. 1985. Laboratory studies with antifungal agents: susceptibility tests and bioassays, p. 991-999. In E. H. Lennette, A. Balows, W. J. Hausler, Jr., and H. J. Shadomy (ed.), Manual of clinical microbiology, 4th ed. American Society for Microbiology, Washington, D.C. Sherwood, J. A., and A. S. Dansky. 1983. Paecilomyces pyelonephritis complicating nephrolithiasis and review of Paecilomyces infections. J. Urol. 130:526-528. Silver, M. D., P. G. Tuffnell, and W. G. Bigelow. 1971. Endocarditis caused by Paecilomyces variotii affecting an aortic valve allograft. J. Thorac. Cardiovasc. Surg. 61:278-281. Smith, J. M. B. 1989. Opportunistic mycoses of man and other animals, p. 193. CAB International, Wallingford, United Kingdom. Swartz, R. D. 1985. Chronic peritoneal dialysis: mechanical and infectious complications. Nephron 40:29-37. Tapson, J. S., H. Mansy, R. Freeman, and R. WilkInson. 1986. The high morbidity of CAPD fungal peritonitis: description of 10 cases and review of treatment strategies. Q. J. Med. 61:10471053. Taylor, P. C., L. A. Poole-Warren, and R. E. Grundy. 1987. Increased microbial yield from continuous ambulatory peritoneal dialysis peritonitis effluent after chemical or physical disruption of phagocytes. J. Clin. Microbiol. 25:580-583. Thompson, R. F., R. B. Bode, J. C. Rhodes, and J. L. Gluckman. 1988. Paecilomyces variotii. An unusual cause of isolated sphenoid sinusitis. Arch. Otolaryngol. Head Neck Surg. 114:567569. Thomson, N. M., J. M. Agar, R. C. Atkdns, D. F. Scott, and T. J. Humphery. 1983. Continuous ambulatory peritoneal dialysis (CAPD): an established treatment for endstage renal failure. Aust. N.Z. J. Med. 13:489-496. Uys, C. J., P. A. Don, V. Schrire, and C. N. Barnard. 1963. Endocarditis following cardiac surgery due to the fungus Paecilomyces. S. Afr. Med. J. 37:1276-1280. Wilken-Jensen, K., and S. Gravesen. 1984. Atlas of moulds in Europe causing respiratory allergy. Foundation for allergy research in Europe, p. 34. ASK Publishing, Copenhagen, Denmark. Wood, G. M., J. G. McCormack, D. B. Muir, D. H. Ellis, M. F. Ridley, R Pritchard, and M. Harrison. 1992. Clinical features of human infection with Scedosporium inflatum. Clin. Infect. Dis. 14:1027-1033.