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Resident PGY 4
Henry Ford Hospital
Introduction: Cryptococcus is an environmental yeast that is typically associated with human immunodeficiency virus (HIV), and transplant recipients. Invasive disease has been described in patients with liver disease, however it is not a common occurrence. We describe a case of disseminated Cryptococcus neoformans infection in a patient with liver cirrhosis. Case presentation: 53-year-old male, with history of Hepatitis C infection, liver cirrhosis, Sjogren’s syndrome, venous thromboembolism (VTE), was admitted to the hospital for worsening debility and weakness. In a recent hospital admission for acute kidney injury (AKI), he was found to have spontaneous bacterial peritonitis secondary to Klebsiella pneumoniae and E. coli, and bacteremia with the latter organism. Patient was treated with IV Ertapenem. On latest admission, patient’s model for end-stage liver disease (MELD)-Na was 25. Physical exam was significant for abdominal distention with mild diffuse tenderness, shifting dullness, positive fluid-wave sign, and bilateral 1+ edema to the knee. Peritoneal fluid was positive for Cryptococcus, and multiple blood cultures (total of 6 different days) were positive for Cryptococcus. Lumbar puncture (LP) showed pleocytosis with monocytes predominance, CSF culture positive for Cryptococcus and a CSF Cryptococcal antigen (CrAg) of 1:2560. Patient was treated with Liposomal Amphotericin B and Flucytosine. Repeated LPs showed persistently elevated opening pressures, requiring ventricular-pleural shunt. He finished a course of 4 weeks of induction therapy, followed by transition to oral Fluconazole for consolidation. Discussion: Cryptococcus neoformans is an encapsulated, ubiquitous, opportunistic yeast. Invasive Cryptococcus disease is a rare but highly morbid infection in patients with liver disease. Peritonitis is common in these patients, especially with high MELD-Na scores. Challenges in diagnosis are due to atypical presentation, mild-moderate fluid pleocytosis, and slow culture turnaround time. Meningitis with Cryptococcus poses a high morbidity condition, especially if complications like elevated intracranial pressure arises. Multiple sites of seeding of Cryptococcus neoformans in an immunocompetent patient is rare. Prompt initiation of adequate therapy and close monitoring of complications are key for improvement in patient’s survival. Treatment is prolonged and challenging.
Parraga Acosta, Tommy and Brar, Indira, "Disseminated Cryptococcal Disease in Liver Cirrhosis" (2019). Case Reports. 36.