Cryptococcal Meningitis Presenting with Alerted Mental Status in a Patient with Cirrhosis: Diagnostic Dilemmas

Abstract

Purpose: Altered mental status is a frequent reason for admission for patients with cirrhosis, and is usually caused by hepatic encephalopathy. In this abstract, we report a patient with cirrhosis who was admitted with altered mental status and eventually found to have cryptococcal meningitis. Case Report: A 48-year-old AA female with cirrhosis caused by NASH was admitted with suspected hepatic encephalopathy. Vital signs showed a temperature of 38.4°C, heart rate of 82 /min, blood pressure of 110/70 mmHg, and respiratory rate of 19 /min. On neurological exam, she was not oriented to time, place, and person, and had no signs of meningism. She did not have any focal neurological signs. Labs: AST/ALT: 46/118, Alk Phos: 251, INR: 1.5; ammonia level was elevated at 52 umol/L. Her electrolytes and renal functions were within normal range. Her MELD was 13. and she had Child Pugh class B. Blood cultures remained negative for any microbial growth. Her HIV test was negative. She was promptly started on lactulose, and started having adequate bowel movements. However, her mental status deteriorated over the next 72 hours, and a lumbar puncture (LP) was performed. CSF studies showed a WBC count of 1875 cells/mm3 (69% neutrophils, 30% lymphocytes), glucose of 30 mg/dl, protein 50 mg/dl and cryptococcal antigen titer of 1:8. CSF cultures grew Cryptococcus neoformans, and she was started on liposomal amphoterecin B. She responded well to treatment, with remarkable improvement in mental status. Discussion:Cryptococcus neoformans meningitis is very uncommon in patients with cirrhosis. Unless the clinician keeps a high index of suspicion, it can be easily missed; especially since every patient with altered mental status is labeled as hepatic encephalopathy. Moreover, LP is difficult in cirrhotic patients, due to coagulopathy and thrombocytopenia, potentially delaying or preventing the diagnostic studies such as CSF culture or crytococcal antigen. While serum crytococcal antigen test is not very sensitive, and false positive tests can occur (in infections with Trichosporon asahii fungus or Stomatococcus and Capnocytophaga bacteriae), one might have to rely solely on serum antigen for a diagnosis in many patients with severe coagulopathy. This diagnostic dilemma is further accentuated by potential toxicities of fungicidal drugs, (amphotericin B and/or flucytosine) in patients with compromised hepatic function and reduced renal function secondary to hepatorenal syndrome. Conclusion: Cryptococcal meningitis can masquerade as hepatic encephalopathy in patients with cirrhosis. A high clinical suspicion, along with early initiation of diagnostic studies and therapies, are needed for effective treatment.