[Clinical cases of complicated diverticulitis against the background of severe course COVID-19. Case report].

Two clinical cases of perforation of a previously undiagnosed colon diverticulum in patients with coronavirus infection caused by the SARS-CoV-2 virus treated at the Hospital №1 of Nalchik. Both patients were elderly, overweight, had a lot of chronic concomitant diseases. Patients received hormone therapy and were targeted: the first patient twice (tocilizumab on the first day of hospitalization and olokizumab on the 7th day of inpatient treatment). The second patient received levilimab on the 3rd day of his stay in the hospital. A short time after targeting, both patients developed acute diffuse abdominal pain, the patients were transferred to the surgical department and operated on. During the operation, both patients were found to have previously undiagnosed diverticular disease, complicated by diverticular perforation and peritonitis on the background of immunosuppression. Both patients died. Thus, when using targeted therapy for patients with COVID-19, it is necessary to take into account that they may have previously undiagnosed chronic diseases that can cause fatal complications against the background of immunosuppression.

Novel Aspects of the Immune Response Involved in the Peritoneal Damage in Chronic Kidney Disease Patients under Dialysis.

Chronic kidney disease (CKD) incidence is growing worldwide, with a significant percentage of CKD patients reaching end-stage renal disease (ESRD) and requiring kidney replacement therapies (KRT). Peritoneal dialysis (PD) is a convenient KRT presenting benefices as home therapy. In PD patients, the peritoneum is chronically exposed to PD fluids containing supraphysiologic concentrations of glucose or other osmotic agents, leading to the activation of cellular and molecular processes of damage, including inflammation and fibrosis. Importantly, peritonitis episodes enhance peritoneum inflammation status and accelerate peritoneal injury. Here, we review the role of immune cells in the damage of the peritoneal membrane (PM) by repeated exposure to PD fluids during KRT as well as by bacterial or viral infections. We also discuss the anti-inflammatory properties of current clinical treatments of CKD patients in KRT and their potential effect on preserving PM integrity. Finally, given the current importance of coronavirus disease 2019 (COVID-19) disease, we also analyze here the implications of this disease in CKD and KRT.

Detection of anti-feline infectious peritonitis virus activity of a Chinese herb extract using geneLEAD VIII, a fully automated nucleic acid extraction/quantitative PCR testing system.

The geneLEAD VIII is a fully-automated nucleic acid extraction/quantitative PCR equipment developed by Precision System Science Co., Ltd., (PSS). To take advantage of its capability, we developed a quantitative assay system to measure growth of animal viruses. The system was used to assay one of the Chinese herbal extracts whose anti-malarial activities were previously reported and demonstrated its dose-dependent anti-viral activity against feline infectious peritonitis virus (FIPV), a feline coronavirus causing the fatal diseases in cats, and relatively low cell toxicity. The assay developed in this study is useful to screen antiviral drugs and the anti-FIPV activity of the herbal extract identified have a potential to lead to development of new drugs against FIPV and other coronaviruses, such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Emergency surgical treatment of colonic acute diverticulitis: a multicenter observational study on behalf of the Italian society of colorectal surgery (SICCR) Lombardy committee.

Colonic diverticulitis can be treated conservatively, but some cases require surgery. Patients can undergo Hartmann's procedure (H) or resection with primary anastomosis (RA), with or without diverting stoma. This multicenter observational retrospective study aims to evaluate the adherence to current guidelines by assessing the rate of RA and H in Lombardy, Italy, and to analyze differences in patients' features. This study included data collected from nine surgical units performing emergency surgery in Lombardy, in 2019 and 2021. Data for each year were retrospectively collected through a survey among Italian Society of Colorectal Surgery (SICCR) Lombardy members. Additional data were about: Hinchey's classification, laparoscopic (VLS) or converted procedures, procedures with more than two operators, procedures in which the first operator was older than 40 years, night or weekend procedures, older-than-80 patients, COVID-19 positivity (just 2021). The total number of operations performed was 254, 115 RA and 130 H (45.3% and 51.2%, diff. 12%, p = 0.73), and 9 (3.5%) other procedures. RAs were more frequent for Hinchey 1 and 2 patients, whereas Hs were more frequent for Hinchey 3 and 4. RAs without ileostomy were significantly less than Hs (66 vs. 130, p = 0.04). Laparoscopy was more used for RA compared to H (57 vs. 21, p = 0.03), whereas no difference was found between RA and H with respect to conversion rate, the presence of more than two operators in the team, the presence of a first operator older than 40 years, night or weekend operations, and for older-than-80 patients. This study confirms the adherence to current guidelines for the treatment of acute colonic diverticulitis in Lombardy, Italy. It can be considered as a preliminary survey with interesting results that may open the way to a further prospective observational study to clarify some aspects in the management of this disease.

Acute Appendicitis Associated With COVID-19 Managed With Individualized Classical Homeopathy: A Case Report (preprint)

Acute appendicitis is the most common surgical emergency worldwide with peak incidence in the age range of 10 – 19 years, and the standard treatment procedure is the surgical removal of the appendix to avoid complications such as its rupture, peritonitis, and sepsis. The COVID-19 pandemic required the global population to stay indoors to stop the spread of virus, which led to a decline in the number of patients visiting the hospital for non- COVID -19 related emergencies. This is a case of a 9-year-old girl who tested positive for COVID -19 and developed acute appendicitis and benefited from individualised classical homeopathy. Further scientific investigation is necessary to establish the relevance of individualised classical homeopathy in treating serious acute conditions such as acute appendicitis.

Growing a peritoneal dialysis program in Palestine from zero to 178 patients in 5 years: a single-center experience.

INTRODUCTION: Kidney failure is rapidly rising in Palestine, as the number of patients receiving maintenance dialysis has quadrupled in the last 15 years. In this study, we share an overview of our experience growing a peritoneal dialysis (PD) program from zero to 178 patients in 5 years at An-Najah National University Hospital in Palestine, presenting some challenges and ways to overcome them. METHODS: This was a single-center retrospective study of patients treated with PD from November 2016 to December 2021. Demographic and clinical data were obtained for each patient. In addition, PD discontinuation, peritonitis, and mortality rates were calculated and presented as the primary patient outcomes. RESULTS: A total of 158 patients were eligible for the study. The mean age was 51.8 ± 16.4 years, and 53.8% of patients were male. Diabetic nephropathy was the most common cause of kidney failure. 63 episodes of peritonitis were diagnosed in 48 patients (30.4%) for a rate of 1 episode/ 38.2 patient-months (0.31 episodes/ patient-years). 20 patients had their PD treatment discontinued, mainly due to psychosocial reasons and infectious and mechanical complications. Death was the fate of 27 patients, with cardiovascular disease and COVID-19 being the two main causes. CONCLUSION: The outcomes of this experience proved favorable and showed that PD could serve as a viable option for kidney failure patients in Palestine. Moreover, this study can serve as an example for other places where circumstances are challenging to take the initiative of starting their PD programs.

Molecular Epidemiology and Risk Analysis for Asymptomatic Infection with Feline Enteric Coronavirus in Domestic and Stray Cats in Japan (preprint)

Feline coronavirus is classified into two coronaviruses: feline enteric coronavirus (FECoV) and feline infectious peritonitis (FIP) virus (FIPV), which cause mild diarrhea and deadly peritonitis in cats, respectively. Since FIPV arises by mutation(s) in FECoV, a survey of FECoV infection in cats is needed to provide fundamental information for prevention of FIP. FECoV also causes subclinical infection; therefore, asymptomatic cats may play a role as a reservoir and transmitter of FECoV. However, there is limited information on the prevalence of FECoV and information from risk analysis of asymptomatic FECoV infection in healthy cats. We conducted a molecular survey of FECoV in normal feces from healthy domestic and stray cats by using nested RT-PCR targeting the FECoV S gene. Interestingly, the RT-PCR-positive rate in domestic cats (35.5%) was significantly higher than that in stray cats (15.9%). Our risk analysis revealed that age less than 1 year and keeping cats indoors are risk factors of asymptomatic FECoV infection. Furthermore, a phylogenetic tree based on partial FECoV S genes suggested transmission of FECoV between domestic cats and stray cats. Our data will contribute to a better understanding of the ecology of FECoV in healthy cats for prevention of FIP.

Peritoneal dialysis-associated peritonitis presenting with Ralstonia pickettii infection: A novel series of three cases during the COVID-19 pandemic.

Peritoneal dialysis (PD)-associated peritonitis secondary to Ralstonia infection is very rare. Ralstonia pickettii is an organism that can grow in contaminated saline, water, chlorhexidine, and other medical products used in laboratories and the clinical setting. Infective endocarditis, prosthetic joint, and severe chest infections are previously reported with R. pickettii infection. We report a novel series of three cases diagnosed with PD-associated peritonitis caused by R. pickettii, where the cases appeared consecutively to our unit during a span of 4 weeks. During the COVID-19 pandemic, there were increased uses of non-sterile gloves by clinical staff as a form of personal protective equipment throughout patient interaction and PD exchange, as recommended by local hospital policy for all staff attending to patient care. A multidisciplinary team root cause analysis of our cases suggested non-sterile gloves being the likely source of environmental contamination, leading to PD-associated peritonitis caused by R. pickettii in this scenario.

Molecular characterization of Feline coronavirus in Shandong from 2017 to 2019, China (preprint)

Feline coronavirus (FCoV) is the causative agent of feline infectious peritonitis and diarrhoea in kittens worldwide. In this study, a total of 73 feline diarrhoeal faecal samples were collected from veterinary hospitals in ShanDong province from 2017 to 2019. FCoV was detected in 58.23% (46/79) of the samples using the RT-nPCR method. The results showed that the detection rate of FCoV in healthy cats and sick cats were 41.7% (10/24) and 81.6% (40/49), respectively. Full gene amplification and sequencing of N, M and S2 of positive FCoV isolates were performed. There was an amino acid mutation site (M1058L) in the S gene, which could be predicted to be used as a marker for Feline enteric coronavirus (FECV) and Feline infectious peritonitis virus (FIPV). These results enriched the epidemiological information of FCoV and provided an important reference for the prevention of FCoV in Shandong.

Estimating the potential overdiagnosis and overtreatment of acute appendicitis in Thailand using a secondary data analysis of service utilization before, during and after the COVID-19 lockdown policy.

INTRODUCTION: Acute appendicitis is one of the most common surgical emergencies; however, optimal diagnosis and treatment of acute appendicitis remains challenging. We used the coronavirus disease 2019 (COVID-19) lockdown policy as a natural experiment to explore potential overdiagnosis and overtreatment of acute appendicitis in Thailand. The aim of this study was to estimate the potential overdiagnosis and overtreatment of acute appendicitis in Thailand by examining service utilization before, during, and after the COVID-19 lockdown policy. METHODS: A secondary data analysis of patients admitted with acute appendicitis under the Universal Coverage Scheme (UCS) in Thailand over a 6-year period between 2016 and 2021 was conducted. The trend of acute appendicitis was plotted using a 14-day rolling average of daily cases. Patient characteristics, clinical management, and outcomes were descriptively presented and compared among three study periods, namely pre-pandemic, lockdown, and post-lockdown. RESULTS: The number of overall acute appendicitis cases decreased from 25,407 during pre-pandemic to 22,006 during lockdown (13.4% reduction) and 21,245 during post-lockdown (16.4% reduction). This reduction was mostly due to a lower incidence of uncomplicated acute appendicitis, whereas cases of generalized peritonitis were scarcely affected by the pandemic. There was an increasing trend towards the usage of diagnostic computerized tomography for acute appendicitis but no significant difference in treatment modalities and complication rates. CONCLUSION: The stable rates of generalized peritonitis and complications during the COVID-19 lockdown, despite fewer admissions overall, suggest that there may have been overdiagnosis and overtreatment of acute appendicitis in Thailand. Policy makers could use these findings to improve clinical practice for acute appendicitis in Thailand and support the efficient utilization of surgical services in the future, especially during pandemics.

Growing a Peritoneal Dialysis Program in Palestine from Zero to 178 Patients in 5 Years: A Single-Center Experience (preprint)

Introduction: Kidney failure is rapidly rising in Palestine, as the number of patients receiving maintenance dialysis has quadrupled in the last 15 years. In this study, we share an overview of our experience growing a peritoneal dialysis (PD) program from zero to 178 patients in five years at An-Najah National University Hospital in Palestine, presenting some challenges and ways to overcome them. Methods: This was a single-center retrospective study of patients treated with PD from November 2016 to December 2021. Demographic and clinical data were obtained for each patient. In addition, PD discontinuation, peritonitis, and mortality rates were calculated and presented as the primary patient outcomes. Results: A total of 158 patients were eligible for the study. The mean age was 51.8 ± 16.4 years, and 53.8% of patients were male. Diabetic nephropathy was the most common cause of kidney failure. Sixty-three episodes of peritonitis were diagnosed in 48 patients (30.4%) for a rate of 1 episode/ 38.2 patient-months (0.31 episodes/ patient-years). Twenty patients had their PD treatment discontinued, mainly due to psychosocial reasons and infectious and mechanical complications. Death was the fate of 27 patients, with cardiovascular disease and COVID-19 being the two main causes. Conclusion: The outcomes of this experience proved favorable and showed that PD could serve as a viable option for kidney failure patients in Palestine. Moreover, this study can serve as an example for other places where circumstances are challenging to take the initiative of starting their PD programs.

Successful Detection of Delta and Omicron Variants of SARS-CoV-2 by Veterinary Diagnostic Laboratory Participants in an Interlaboratory Comparison Exercise (preprint)

Background: Since the beginning of the COVID-19 pandemic veterinary diagnostic laboratories have tested diagnostic samples for SARS-CoV-2 not only in animals, but in over five million human samples. An evaluation of the performance of those laboratories is needed using blinded test samples to ensure that laboratories report reliable data to the public. This interlaboratory comparison exercise (ILC3) builds on two prior exercises to assess whether veterinary diagnostic laboratories can detect Delta and Omicron variants spiked in canine nasal matrix or viral transport medium. Methods: Inactivated Delta variant at levels of 25 to 1,000 copies per 50 microliters of nasal matrix were prepared for participants by the ILC organizer, an independent laboratory, for blinded analysis. Omicron variant at 1,000 copies per 50 microliters of transport medium was also included. Feline infectious peritonitis virus (FIPV) RNA was used as a confounder for specificity assessment. A total of 14 test samples were prepared for each participant. Participants used their routine diagnostic procedures for RNA extraction and real-time RT-PCR. Results were analyzed according to International Organization for Standardization (ISO) 16140 - 2:2016. Results: The overall results showed 93% detection for Delta and 97% for Omicron at 1,000 copies per 50 microliters (22-200 copies per reaction). The overall specificity was 97% for blank samples and 100% for blank samples with FIPV. No differences in Ct values were significant for samples with the same virus levels between N1 and N2 markers, nor between the two variants. Conclusions: The results indicated that all ILC3 participants were able to detect both Delta and Omicron variants. The canine nasal matrix did not significantly affect SARS-CoV-2 detection.

[Negative impact of COVID-19 pandemic on peritonitis rate in peritoneal dialysis patients: Pleading for a continuous educational training]. / Conséquences de la pandémie de COVID-19 sur le taux de péritonites de dialyse péritonéale : plaidoyer pour une formation continue ininterrompue.

BACKGROUND: Peritonitis is a common complication of chronic peritoneal dialysis treatment contributing to both technique failure and/or death. Little is effectively known about the actual benefits of a continuous training program on peritonitis rates. In the present study, we measured the impact of our patients' training protocol on peritonitis rates. We further studied which consequences the COVID-related disruption of our follow-up program had on peritonitis rates. METHODS: We present our yearly peritonitis rates since our patients' training and retraining program was implemented in 2010. We then focused our study on three consecutive years: 2019, 2020 (emergence of COVID-19), and 2021, collecting microbiological data from each peritonitis episode. Statistical analysis were used to corroborate our findings. RESULTS: Since 2010, peritonitis rates declined linearly (R2=0,6556; df=8; P<0.01) until its nadir in 2019 with 4 peritonitis episodes. The majority of infections were then treated in the outpatient Clinic. In 2020, our continuous technique evaluation decreased by 51% and 28 peritonitis episodes occurred, 47% secondary to strict cutaneous bacteria's, and 31% gastro-intestinal, irrespective of patients' experience or peritoneal dialysis modality. The hospitalization rate reached 71%. Having restored our protocol, we decreased peritonitis rates by 50% in 2021. CONCLUSIONS: Risk factors for peritonitis are identifiable and modifiable and require sustained intervention, continuous visual monitoring and training. These interventions significantly reduce peritonitis rates. Any brief interruption to patients' technique evaluation may elevate peritonitis rates significantly.

[Mortality in acute appendicitis in Russia]. / Letal'nost' pri ostrom appenditsite v Rossii.

OBJECTIVE: To analyze the causes of mortality in patients with acute appendicitis in Russia. MATERIAL AND METHODS: We retrospectively studied mortality in patients with acute appendicitis in the Russian Federation in 2020. We surveyed the hospitals with mortality reported in the electronic database of annual reports to the chief surgeon of the Ministry of Health of the Russian Federation. RESULTS: There were 259 deaths among 150.393 patients with acute appendicitis aged ≥18 years (in-hospital mortality 0.17%). We obtained data about 95.8% (n=248) of lethal cases including 86.3% (n=214) complicated and 13.7% (n=34) uncomplicated forms of disease. Two patients died without surgery (0.8%). Among the deceased, 58.2% (n=145) were men and 41.8% (n=103) were women. Mean patient age was 66.2 years [0.95% CI 64.2-68.1]. The main cause of death in complicated appendicitis was late presentation (after 4.9 days [0.95% CI 4.3-5.4]) that resulted peritonitis and sepsis in 71.5% (n=153) of patients. Cardiovascular diseases were noted in 23.4% (n=50) of cases. A new coronavirus infection was detected in 7.0% (n=15) of patients. However, COVID-19 as a direct cause of death was recognized in 2.8% (n=6) of cases. Other reasons accounted for 2.3% (n=5). In uncomplicated appendicitis, cardiovascular diseases were the main cause of mortality (73.5%, n=25). Peritonitis and sepsis were found in 11.8% (n=4) of cases, COVID-19 - in 5.9% (n=2). Other causes accounted for 8.8% (n=3). Diagnostic, tactical, technical problems and their combination were revealed in 54.4% of lethal outcomes. CONCLUSION: Mortality from acute appendicitis in the Russian Federation is low, comparable with international data, and mainly associated with delayed treatment and complicated course of disease. However, the impact of diagnostic, tactical and technical errors on the outcome of acute appendicitis is significant.

Ileo-colic lipomatosis complicated by cecum perforation and mimicking acute appendicitis: a case report.

Lipomatosis of the colon is rare in clinical practice although the majority of cases are found incidentally. In rare circumstances, patients may presents with acute complications such as bowel obstruction, intussusception, or perforation. Here we report a case of colonic lipomatosis that present as localized peritonitis mimicking acute appendicitis in a young COVID patient. Sixth case in the literature of intestinal perforation peritonitis in intestinal lipomatosis.

[Severe pseudomembranous colitis in patients with previous coronavirus infection]. / Psevdomembranoznyi kolit na fone perenesennoi koronavirusnoi infektsii.

OBJECTIVE: To analyze treatment outcomes in patients with severe pseudomembranous colitis and previous coronavirus infection. MATERIAL AND METHODS: We retrospectively analyzed treatment outcomes, clinical, laboratory and histological data in convalescents of COVID-19 who admitted to the department of coloproctology for moderate-to-severe pseudomembranous colitis confirmed by endoscopic examination between 2020 and 2021. RESULTS: There were 13 patients with moderate pseudomembranous colitis and 6 ones with severe pseudomembranous colitis. Mean period after recovery from coronavirus infection was 19 days. Endoscopy revealed whitish-yellow or gray raised plaques on colonic mucosa in all cases. Four patients with signs of peritonitis underwent emergency surgery. Three patients had perforation of caecum; one patient had perforation of sigmoid colon and widespread peritonitis. Two patients underwent urgent surgery for progressive toxic megacolon and ineffective therapy. Subtotal colectomy and ileostomy were performed in all cases. Histological examination revealed necrosis of not only superficial layer of colon mucosa typical for clostridial colitis, but also the entire thickness of mucosa, as well as submucosal and partially muscular layers in some cases. Mucosal crypt atrophy, fibrinoid effusion in muscular layer, diffuse polymorphonuclear cell infiltration and necrosis of muscular and submucosal nerve plexuses, as well as necrosis of vascular walls with deposition of hyaline-like structures characterize microcirculatory ischemic processes in the colon wall. CONCLUSION: Severe pseudomembranous colitis associated with COVID-19 may not be associated with clostridial infection. Further analysis of possible ischemic etiology and pathogenesis of gastrointestinal lesions in COVID-19 is needed for preventive and therapeutic measures.

Abdominal drainage to prevent intra-peritoneal abscess after appendectomy for complicated appendicitis.

BACKGROUND: This is the second update of a Cochrane Review first published in 2015 and last updated in 2018. Appendectomy, the surgical removal of the appendix, is performed primarily for acute appendicitis. Patients who undergo appendectomy for complicated appendicitis, defined as gangrenous or perforated appendicitis, are more likely to suffer postoperative complications. The routine use of abdominal drainage to reduce postoperative complications after appendectomy for complicated appendicitis is controversial. OBJECTIVES: To assess the safety and efficacy of abdominal drainage to prevent intraperitoneal abscess after appendectomy (irrespective of open or laparoscopic) for complicated appendicitis; to compare the effects of different types of surgical drains; and to evaluate the optimal time for drain removal. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, Web of Science, the World Health Organization International Trials Registry Platform, ClinicalTrials.gov, Chinese Biomedical Literature Database, and three trials registers on 24 February 2020, together with reference checking, citation searching, and contact with study authors to identify additional studies. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) that compared abdominal drainage versus no drainage in people undergoing emergency open or laparoscopic appendectomy for complicated appendicitis. We also included RCTs that compared different types of drains and different schedules for drain removal in people undergoing appendectomy for complicated appendicitis. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We used the GRADE approach to assess evidence certainty. We included intraperitoneal abscess as the primary outcome. Secondary outcomes were wound infection, morbidity, mortality, hospital stay, hospital costs, pain, and quality of life. MAIN RESULTS: Use of drain versus no drain We included six RCTs (521 participants) comparing abdominal drainage and no drainage in participants undergoing emergency open appendectomy for complicated appendicitis. The studies were conducted in North America, Asia, and Africa. The majority of participants had perforated appendicitis with local or general peritonitis. All participants received antibiotic regimens after open appendectomy. None of the trials was assessed as at low risk of bias. The evidence is very uncertain regarding the effects of abdominal drainage versus no drainage on intraperitoneal abscess at 30 days (risk ratio (RR) 1.23, 95% confidence interval (CI) 0.47 to 3.21; 5 RCTs; 453 participants; very low-certainty evidence) or wound infection at 30 days (RR 2.01, 95% CI 0.88 to 4.56; 5 RCTs; 478 participants; very low-certainty evidence). There were seven deaths in the drainage group (N = 183) compared to one in the no-drainage group (N = 180), equating to an increase in the risk of 30-day mortality from 0.6% to 2.7% (Peto odds ratio 4.88, 95% CI 1.18 to 20.09; 4 RCTs; 363 participants; low-certainty evidence). Abdominal drainage may increase 30-day overall complication rate (morbidity; RR 6.67, 95% CI 2.13 to 20.87; 1 RCT; 90 participants; low-certainty evidence) and hospital stay by 2.17 days (95% CI 1.76 to 2.58; 3 RCTs; 298 participants; low-certainty evidence) compared to no drainage. The outcomes hospital costs, pain, and quality of life were not reported in any of the included studies. There were no RCTs comparing the use of drain versus no drain in participants undergoing emergency laparoscopic appendectomy for complicated appendicitis. Open drain versus closed drain There were no RCTs comparing open drain versus closed drain for complicated appendicitis. Early versus late drain removal There were no RCTs comparing early versus late drain removal for complicated appendicitis. AUTHORS' CONCLUSIONS: The certainty of the currently available evidence is low to very low. The effect of abdominal drainage on the prevention of intraperitoneal abscess or wound infection after open appendectomy is uncertain for patients with complicated appendicitis. The increased rates for overall complication rate and hospital stay for the drainage group compared to the no-drainage group are based on low-certainty evidence. Consequently, there is no evidence for any clinical improvement with the use of abdominal drainage in patients undergoing open appendectomy for complicated appendicitis. The increased risk of mortality with drainage comes from eight deaths observed in just under 400 recruited participants. Larger studies are needed to more reliably determine the effects of drainage on morbidity and mortality outcomes.

COVID 19 Pneumonia and a Rare Form of Fungal Peritonitis in a Patient Survivor on Peritoneal Dialysis.

Peritoneal dialysis (PD) related peritonitis is usually caused by bacteria, but viruses and fungi could also affect the peritoneal membrane and cause cloudy effluent with negative bacterial cultures. We present a case of a PD patient who survived fungal peritonitis caused by Geotrichum klebahnii (March 2015) and COVID-19 pneumonia (April 2021) with peritonitis probably caused by the SARS-CoV-2 virus. The fungal peritonitis followed one episode of exit-site infection and two episodes of bacterial peritonitis treated with a wide-spectrum antibiotic. The patient's PD catheter was removed immediately upon the diagnosis of fungal peritonitis, and an antifungal treatment was continued for 3 weeks after catheter removal. The new peritoneal catheter was reinserted 8 weeks after complete resolution of peritonitis, and the patient continued treatment with PD. The patient developed severe Covid-19 pneumonia with a sudden appearance of cloudy peritoneal effluent. There was no bacterial or fungal growth on the effluent culture. A PCR test for SARS-CoV-2 in peritoneal effluent was not performed. The peritoneal effluent became transparent with the resolution of the severe symptoms of Covid-19 pneumonia.