P3013 - Difficult Diagnosis of Disseminated Cryptococcosis in a Patient With Cirrhosis

Emma Russell, BS¹, Yizhong Wu, MD², Manuel Garza, MD, MS³, Sanjay Prasad, MD³, Kim Minh Le, DO⁴, Wasay A. Mohajir, DO³, MaryAnn Tran, MD³, Raja K. Dhanekula, MS, MD, MBBS^5
1Texas A&M School of Medicine, Round Rock, TX; ²Baylor Scott & White Medical Center, Georgetown, TX; ³Baylor Scott & White Medical Center, Round Rock, TX; ⁴Baylor Scott & White Medical Center, Austin, TX; ⁵Baylor Scott and White Round Rock, Round Rock, TX

Introduction: Patients with cirrhosis are at higher risk for spontaneous bacterial peritonitis (SBP), urinary tract infections (UTI), and infection by opportunistic organisms. Cirrhosis is an independent risk factor for cryptococcal infection, a disease where meningeal involvement is associated with high morbidity and mortality. We present a case of new onset seizures and cerebral infarcts in a patient with cirrhosis eventually diagnosed as cryptococcal meningitis.

Case Description/Methods: A 66-year-old man with decompensated alcohol related cirrhosis (MELD 3.0 score 28, Child-Pugh class C) and HCC presented for new body stiffness and shaking in the setting of one week of headaches. Vital signs were unremarkable. The physical exam was pertinent for a distended but non-tender abdomen, with no focal deficits. He last used alcohol two months prior. MRI showed acute/subacute basal ganglia and temporal infarcts (Figure 1). His seizures resolved after starting levetiracetam and was discharged. One week later, he returned to the hospital with intermittent fevers and ascitic fluid cultures that grew gram negative rods. On the physical exam, he was alert and oriented with a distended, tender abdomen. He was treated for SBP. Within five days, his mentation progressively declined, and he developed asterixis. Lactulose was up titrated and rifaximin was added. His ammonia level was 21 mcg/dL. Despite treatment, he became minimally arousable. He did not exhibit evidence of UTI or pneumonia, and there were no signs of blood loss. Further work-up revealed an elevated cryptococcus antigen of 1:4096 in serum. Subsequent lumbar puncture revealed an opening pressure of 29 cm H2O, protein 357.2 mg/dL, glucose 2 mg/100mL, and positive cryptococcus PCR in cerebrospinal fluid (CSF). Amphotericin B and flucytosine were initiated, and the patient was transferred for higher level of care and serial lumbar punctures. Unfortunately, the patient expired shortly after.

Discussion: This unique case highlights the importance of investigating other etiologies when a cirrhotic patient declines despite appropriate medical therapy. Alternative diagnoses such as opportunistic infections are high on the differential in patients with decompensated cirrhosis given their immunocompromised state. Systemic diagnostic reasoning is paramount for the diagnosis of disseminated cryptococcosis, given it is an easily missed, aggressive, and life-threatening disease.



Disclosures:


Emma Russell, BS¹, Yizhong Wu, MD², Manuel Garza, MD, MS³, Sanjay Prasad, MD³, Kim Minh Le, DO⁴, Wasay A. Mohajir, DO³, MaryAnn Tran, MD³, Raja K. Dhanekula, MS, MD, MBBS⁵. P3013 - Difficult Diagnosis of Disseminated Cryptococcosis in a Patient With Cirrhosis, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.