Introduction: Decompensated cirrhosis is underrecognized as an immunosuppressive state. A recent case of cryptococcal meningitis in a patient with acute on chronic liver failure helps illustrate this statement, as well as highlight the importance of identifying cirrhotic patients who are at risk for invasive fungal infections. There is research in patients with AIDS-related cryptococcal meningitis, but only a few studies and case reports suggest cirrhosis as an independent risk factor. Cryptococcal infections are linked with increased mortality risk as well as increased intracranial pressure/neurological complications.
Description: 61 year old male with decompensated alcohol cirrhosis presented with hypotension, frequent falls, and worsening mentation. Blood cultures and paracentesis were done and he was started on broad spectrum antibiotics. One day into his admission, patient suffered a generalized tonic clonic seizure requiring emergent intubation. Lumbar puncture was positive for cryptococcal meningitis with normal opening pressure. He was started on Ambisome and Flucytosine as well as multiple different antiepileptic medications to control ongoing seizures detected on EEG monitoring. With reassuring opening pressure and coagulopathy, intracranial pressure monitoring was deferred. Four days into his hospitalization, patient was noted to have loss of pupillary reflexes with a neurological pupil index of 0. With grim prognosis, family elected to proceed with comfort care.
Discussion: The outcome in this patient was unfavorable as he ended up suffering complications from intracranial hypertension, despite having a normal opening pressure on initial diagnostic lumbar puncture. Retrospective evaluation of management in this case raises the question about considering fungal infections as an underlying infectious etiology earlier in cirrhotic patients, as well as, having suspicion for meningitis in a patient who is presenting for work-up of hepatic encephalopathy. Whether these patients with cryptococcal meningitis need invasive cranial pressure monitoring regardless of initial intracranial pressure readings should also be evaluated. This case emphasizes the need for better diagnostic work-up and management of fungal infections in decompensated cirrhotic patients who are immunosuppressed patients.
