A Unique Case of Disseminated Cryptococcosis in the Setting of Hepatitis C Cirrhosis

Abstract

Introduction: Cryptococcus neoformans can be pathogenic in immuno-compromised hosts and in patients with chronic organ failure. Cryptococcal peritonitis is a rare manifestation of cryptococcosis. Although several cases of spontaneous cryptococcal peritonitis have been reported, their clinical characteristics remain ill-defined. Case Report: A 63-year-old male with hepatitis C cirrhosis presented with worsening ascites without constitutional or focal abdominal symptoms. Physical examination revealed stable vital signs, mild jaundice, and obvious ascites. Large-volume paracentesis revealed WBC of 510/mm3 with lymphocytic predominance (33%) and segmented neutrophils (17%). Serum-ascites albumin gradient (SAAG) was 1.5 g/L. Concomitant blood and ascitic fluid cultures grew Cryptococcus neoformans. HIV screening was negative. Cerebrospinal fluid (CSF) was positive for Cryptococcus antigen. He was treated with liposomal amphotericin-B, flucytosine, and cefepime, and developed renal failure that required hemodialysis. Subsequently, the infection was cleared from the blood stream, peritoneal fluid, and CSF, but he continued to deteriorate clinically with multi-organ failure. He eventually died because of respiratory failure. Conclusion: Spontaneous cryptococcal peritonitis in patients with liver cirrhosis may be an indicator of disseminated Cryptococcosis. Routine examination of ascitic fluid India ink preparation and/or serum cryptococcal antigen in these patients should be considered, especially when there is ascitic fluid with lymphocyte predominance. Clinical awareness of this entity may lead to early diagnosis and timely treatment.