Patient in Acute Liver Failure Having Yeast in the Blood Is Not Always a Candida Infection

Abstract

Purpose: A 50-year-old African-American woman with a past medical history of sarcoidosis (on high dose prednisone up to 40 mg/day intermittently), gastric adenocarcinoma s/p subtotal gastrectomy, who initially presented for a 6-8 week history of anorexia, early satiety, abdominal pain, nausea, and vomiting at an outlying hospital. She had no history of recent travel, toxin exposure, sick contacts, illicit drug use, alcohol use, smoking, or history of tuberculosis. Her CT abdomen showed hepatomegaly, splenomegaly, mediastinal lymph nodes, mesenteric lymph nodes, omental enhancement, and ascites. She underwent a liver biopsy, which revealed stage III, stage IV cirrhosis and findings suggestive of autoimmune hepatitis versus viral hepatitis. In addition, the patient was found to have positive blood and Port-A-Cath cultures for Salmonella group B. Her Port-A-Cath was removed and PICC line placement was done. Subsequently she was transferred to UMDNJ for further work-up. On physical examination, her initial vitals were stable; she was cachectic, icteric, the spleen was palpable in lower left inferior costal margin, the liver was at 5 cm below the right inferior costal margin but no fluid wave or shifting dullness on abdominal exam. She had left upper extremity PICC line. Rest of her examination was unremarkable. Her laboratory findings showed WBC 14.1, 87 % neutrophils, Hgb 9.1, Hct 26.2, platelet 26, HIV (-), AST 146, ALT 246, bilirubin 18.7 with direct bilirubin 16.1, Alk Phos 419. On the first day, her blood cultures showed yeast in the blood. She was started on vancomycin, piperacillin-tazobactam and micafungin. Patient was found to have intermittent fevers despite empiric antibiotic coverage. Over the next 48 hours, patient developed shortness of breath, hypotension, and became hypoxic, so she was intubated and transferred to the ICU. After aggressive fluid resuscitation, she was started on three vasopressors. Eventually she was coded for PEA, but after a prolonged resuscitation trial she expired. After her death, her blood cultures grew Cryptococcus neoformans from the all samples. Her autopsy showed involvement lungs, GI tract, liver, spleen, lymph nodes, and brain. Humans likely become infected with Cryptococcus neoformans by inhaling the small poorly encapsulated yeasts. With a decline in cell-mediated immunity (immunocompromised), cryptococci is able to disseminate throughout the whole body. Most common sites of infection are brain, lungs and skin but virtually can affect any organs but very rarely involve bone, joints, GI tract, muscles, heart and blood vessels. It is important to check for Cryptococcus in immunocompromised patients.