Baker’s yeast might not always be good for everyone – a case of percutaneous gastrostomy tube induced Saccharomyces cerevisiae peritonitis in an immunocompromised patient
Mohammad N. Kloub1, Muhammad Hussain2, Fnu Marium3, Atheer Anwar4, Ahmad Haddad1, Jihad Slim5, Yatinder Bains2
1 Department of Internal Medicine, Saint Michael’s Medical Center, Newark, USA
2 Department of Internal Medicine, Division of Gastroenterology and Hepatology, Saint Michael’s Medical Center, Newark, USA
3 Jinnah Sindh Medical University, Karachi, Pakistan
4 General Physician
5 Department of Infectious Disease, Saint Michael’s Medical Center, Newark, USA
Doi: 10.12890/2024_004354 - European Journal of Case Reports in Internal Medicine - © EFIM 2024
Received: 03/02/2024
Accepted: 19/02/2024
Published: 04/03/2024

How to cite this article: Kloub MN, Hussain M, Marium F, Anwar A, Haddad A, Slim J, Bains Y. Baker’s yeast might not always be good for everyone – a case of percutaneous gastrostomy tube induced Saccharomyces cerevisiae peritonitis in an immunocompromised patient. EJCRIM 2024;11:doi:10.12890/2024_004354.

Conflicts of Interests: The authors declare there are no competing interests.
Patient Consent: Written informed consent was obtained from the patient for publication of the details of their medical case and any accompanying images.
Acknowledgement: The authors would like to acknowledge the internal medicine department at Saint Micheal’s Medical Center for supporting this publication.
This article is licensed under a Commons Attribution Non-Commercial 4.0 License

ABSTRACT

Peritonitis, the inflammation of the protective membrane surrounding parts of the abdominal organs, is a common clinical pathology with multifactorial aetiologies. While bacterial infections are well-recognised as a cause of peritonitis, fungal infections remain relatively uncommon especially Saccharomyces cerevisiae, which is commonly used for breadmaking and as a nutritional supplement. This fungus has been reported to induce peritonitis in patients on peritoneal dialysis. However, it has never been reported as secondary to percutaneous endoscopic gastrostomy (PEG) tube insertion in immunocompromised patients. We present a 64-year-old female with a history of human immunodeficiency virus (HIV) who developed S. cerevisiae peritonitis following PEG tube insertion. The case highlights the importance of considering rare organisms when treating immunocompromised patients with peritonitis, especially after gastrointestinal tract penetration or peritoneal membrane disruption.

KEYWORDS

Percutaneous gastrostomy tube, Saccharomyces cerevisiae, peritonitis, HIV

LEARNING POINTS

INTRODUCTION

The peritoneum is a significant membrane of squamous cells covered by microvilli, and it consists of two layers – the parietal and visceral peritoneum. While the parietal peritoneum lines the inner walls of the peritoneal cavity, the visceral peritoneum covers the surface of numerous intra-abdominal organs. Inflammation of the peritoneal layers is called peritonitis, which can be classified into primary or secondary. Primary peritonitis is characterised by inflammation of the peritoneum with no previous intra-abdominal pathology. However, secondary peritonitis, which is associated with pre-existing abdominal pathology, is much more common[1].
Secondary peritonitis has a variety of underlying causes and can be infectious or non-infectious. Common causes of infectious peritonitis include trauma and spillage of infected material from the intestinal tract or urogenital tract, or after contamination during surgical procedures. Although bacteria are the most predominant organisms in infectious peritonitis, fungal infection should be considered a critical differential diagnosis especially in immunocompromised patients, as early recognition and treatment can change the prognosis. Different fungi were reported in the literature to cause peritonitis S. cerevisiae, also referred to as baker’s yeast or brewer’s yeast, which is considered a healthy fungus that is frequently used for baking bread and fermenting alcohol, is also reported to induce peritonitis, mainly in patients on peritoneal dialysis. We present a report of a patient with S. cerevisiae peritonitis one month after insertion of the PEG tube, and a comprehensive review of S. cerevisiae infections[1,2].

CASE DESCRIPTION

A 64-year-old female with a past medical history of coronary artery disease, congestive heart failure, left ventricular thrombus, cerebrovascular accident, HIV on doravirine and dolutegravir, and pre-diabetes presented to the emergency department from the rehabilitation centre. Her chief complaint was an altered mental state and respiratory distress. Of note, she was admitted twice in the three months before this presentation for ST-elevation myocardial infarction, followed by an acute exacerbation of congestive heart failure (ejection fraction of 10%–15%). She also had a PEG tube placement during the last admission one month earlier, due to low caloric intake. She has smoked one pack per day for 47 years and smokes crack cocaine (four bottles per day). She denied any alcohol abuse. Her medications include rivaroxaban, metoprolol succinate, losartan, aspirin, clopidogrel, darunavir/dolutegravir and albuterol/fluticasone/umeclidinium bromide inhalers. Family and surgical history are unremarkable.
On admission, she was hypotensive (58/34 mm of mercury), tachypnoeic (respiratory rate of 26), and saturating 97% on a 2-litre nasal cannula. Her heart rate was normal as she was on beta blocker. She was febrile with a Tmax of 38 °C. On examination, she was awake and alert but not oriented. The cardiovascular examination was remarkable for S3, but normal S1 and S2, and the respiratory examination revealed bilateral crackles. She has +2 bilateral pitting oedema. An abdomen examination revealed a tender abdomen with foul-smelling fluid leaking from the PEG tube site. The PEG tube site was indurated with erythema, and the bumper was lightly attached to the skin (Fig. 1).

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Figure 1. PEG tube site indurated with erythema.

Chest X-ray showed pulmonary vascular congestion with mild bilateral pleural effusion. A CT scan of the abdomen with oral contrast showed moderate ascites with extensive mesenteric and omental fat stranding, and she was admitted to the medical intensive care unit for septic shock secondary to peritonitis. As shown in Table 1, laboratory tests were significant for leukocytosis and elevated inflammatory markers. Liver function tests were normal. HIV-1 RNA by polymerase chain reaction test was undetectable with an absolute CD4 cell count of 93. The Fungitell® test value was 404 pg/ml (negative result if value less than 60 pg/ml). The patient was started on supportive measures; paracentesis was performed, and 1800 ml of cloudy ascitic fluid was removed.

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Table 1. Blood test results at the time of PEG tube placement and on admission.

Culture of the ascitic fluid grew S. cerevisiae and Escherichia coli. The PEG tube was removed, and the patient was started on piperacillin/tazobactam followed by ceftriaxone since E. coli was sensitive to ceftriaxone. She was also started on micafungin after fungal culture grew S. cerevisiae. Due to persistent leakage from the old PEG tube site, a Steris Padlock Clip® was applied endoscopically (Fig. 2). The fever resolved after a few days of antimicrobial treatment, and inflammatory markers were trending down with the Fungitell® test. The patient passed away during hospitalisation due to acute coronary syndrome on top of her underlying comorbidities.

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Figure 2. Steris Padlock Clip® was applied endoscopically to close the PEG tube site.

DISCUSSION

Also known as baker’s yeast or brewer’s yeast, S. cerevisiae is a strain of yeast commonly used for breadmaking and alcoholic fermentation, recently gaining attention as a nutritional supplement by health enthusiasts. Due to its simple eukaryote nature and its many similarities with human chromosomes, S. cerevisiae is considered a model organism[2]. Thus, it can effectively mimic the biochemical and biological mechanisms of diseases found in humans. S. cerevisiae’s properties have been commonly utilised as a prophylaxis against gastrointestinal conditions, including antibiotic-associated diarrhoea, ulcerative colitis, and clostridium difficile infection (CDI)[3]. Its presence within the human body naturally decreases the likelihood that the yeast manifests as a pathology or infection; the yeast is typically considered non-pathogenic[4].
Mechanisms by which S. cerevisiae infection can occur are either translocation from the gastrointestinal (GI) tract or breaches in the skin barrier, primarily in the setting of indwelling intravascular devices. Clinical reports concerning S. cerevisiae infections have highlighted GI-derived saccharomycopsis following consumption of the yeast in significant doses (e.g. 107–1010 yeast cells/day) from foods or probiotics used for treatment or prophylaxis of diarrhoeal disease, in immunocompetent as well as immunosuppressed patients[5]. However, invasive S. cerevisiae disease after abdominal surgery was also reported in the absence of probiotics consumption[6,7], likely convincing its role as a coloniser.
An in vitro epithelial barrier model by Perez-Torrado et al.[8] revealed that S. cerevisiae has a low ability for epithelial adherence and restricted capacity to induce epithelial cytotoxicity or disrupt intestinal barrier integrity. Therefore, it requires both intestinal barrier dysfunction and a large enteral fungal burden to cause systemic infection[8]. In this immunosuppressed patient (HIV with acquired immunodeficiency syndrome) colonised by S. cerevisiae, the PEG tube insertion disrupts the intestinal barrier and leads to peritonitis. The culture of the ascitic fluid grew E. coli, which can be the cause of the peritonitis. However, a positive S. cerevisiae culture, in view of an elevated Fungitell® test value that trended down with treatment with antifungal, raised the suspicion of fungal peritonitis.
In the literature, there are published cases of peritonitis caused by this yeast in ambulatory peritoneal dialysis patients. However, we are reporting the first case of peritonitis associated with a PEG tube in an HIV patient.
S. cerevisiae colonies grow on Sabouraud dextrose agar as white-cream, smooth, moist colonies. They produce β-d-Glucan and therefore can be used as a surrogate marker for invasive disease, as reported in the case series[9]. However, no clinical studies have evaluated the diagnostic performance of this marker in this infection. In our case, we utilise this marker to monitor the response to therapy. Susceptibility testing for S. cerevisiae can be performed by disc diffusion and both micro- and macro-dilution methods. Choices of antifungal are variable in the literature as certain reports preferred amphotericin B, while others used caspofungin. Nonetheless, the sensitivity of culture offers helpful guidance[7,10,11].
In the literature, there are published cases of peritonitis caused by this yeast in ambulatory peritoneal dialysis patients[11]. To our knowledge, this is the first case of S. cerevisiae peritonitis associated with a PEG tube in an HIV patient. In this immunosuppressed patient (HIV with acquired immunodeficiency syndrome) colonised by S. cerevisiae, PEG tube insertion disrupted the intestinal barrier and led to peritonitis.

CONCLUSION

S. cerevisiae peritonitis is a rare but life-threatening complication of intestinal barrier disruption. This report highlights the importance of considering unusual pathogens, especially when evaluating immunocompromised patients with peritonitis following abdominal organ barrier disruption. Early recognition and prompt treatment are crucial for successful management.

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