P0815 - Death Within Hours From Spontaneous Cryptococcal Peritonitis and Fungemia

Mohammed Ansari, MD¹, Bilal Ashraf, MD², Ramy Abdelmaseih, MD², Randa Abdelmasih, MD², Thomas Brown, MD^1
1University of Central Florida College of Medicine, Ocala, FL; ²Ocala Regional Medical Center, Ocala, FL

Introduction: Spontaneous bacterial peritonitis is ascitic fluid infection without a surgically treatable source, we present a case of cryptococcal peritonitis and cryptococcal fungemia causing death within hours of diagnosis.

Case Description/Methods: A 78-year-old female with history of non-alcoholic fatty liver disease, hepatocellular carcinoma s/p trans-arterial chemo-embolization (1 Yr ago) and recurrent ascites requiring paracentesis every 2-3 weeks was admitted to hospital with worsening ascites and dyspnea. Patient was afebrile and vitally stable on admission. Lab results showed white blood cell count of 16.6 x 10³/mm ³, INR 1.63, BUN 57mg/dL, Cr 2.2mg/dL, total bilirubin 4.7mg:dL, ALT 72U/L, AST 26U/L, ALKP 166U/L, Albumin 2.8g/dL, alpha-fetoprotein 3.6ng/mL and MELD-Na score was 32. Computed tomography (CT) of abdomen and pelvis showed severe cirrhosis, moderate ascites, splenomegaly and thickening of colon (colitis). Empiric treatment with ceftriaxone was started for suspected spontaneous bacterial peritonitis. Initial cytology showed budding yeast and pseudo-hyphae and micafungin was started. Two days after the paracentesis, culture of ascitic fluid grew Cryptococcus neoformans. Micafungin was switched with fluconazole. Blood cultures were positive for C. neoformans. The patient worsened acutely on day 5 requiring ventilator and pressor support but passed away shortly after.

Discussion: Clinical suspicion in cirrhotic patients who continue to be febrile post antibiotics should be high for cryptococcal peritonitis. Early treatment is key in saving lives. No standard antifungal therapy has been proven to be effective. There is evidence to support that underlying liver disease is a major predisposing factor to cryptococcal peritonitis and the risk of developing cryptococcal peritonitis in patients with cirrhosis might be greater than those with immunosuppression and AIDS.


Figure: Figure 1: Ascites (red arrow) hepatomegaly (blue arrow) and splenomegaly (yellow arrow).


Disclosures:
Mohammed Ansari indicated no relevant financial relationships.
Bilal Ashraf indicated no relevant financial relationships.
Ramy Abdelmaseih indicated no relevant financial relationships.
Randa Abdelmasih indicated no relevant financial relationships.
Thomas Brown indicated no relevant financial relationships.


Mohammed Ansari, MD¹, Bilal Ashraf, MD², Ramy Abdelmaseih, MD², Randa Abdelmasih, MD², Thomas Brown, MD¹. P0815 - Death Within Hours From Spontaneous Cryptococcal Peritonitis and Fungemia, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.