S5857 A Unique Case of Probiotic Fungemia in a Cirrhosis Patient

Introduction: Immune dysfunction in cirrhosis predisposes patients to serious infections. While bacterial infections are well documented, data on fungal infections and their management is limited. We present a unique case of probiotic fungemia in a patient with cirrhosis. Case Description/Methods: A 61-year-old man with alcohol-associated cirrhosis decompensated by ascites requiring frequent large volume paracentesis, hepatic encephalopathy (HE) and chronic kidney disease was admitted for altered mental status. On presentation labs included aspartate aminotransferase 32 U/L, alanine aminotransferase 16 U/L, total bilirubin 2.1 mg/dL, alkaline phosphatase 64 U/L, international normalized ratio 1.3 and Model for End-Stage Liver Disease 3.0 of 30. A full infectious workup including a diagnostic paracentesis was initially negative for infection. The patient’s mentation improved with optimization of lactulose and rifaximin however hospitalization was prolonged by renal failure and recurrent grade 3 HE leading to aspiration requiring intubation. Patient subsequently had hypotension refractory to resuscitation with a BP of 75/50 requiring norepinephrine 0.22 mcg/kg/min and vasopressin 0.04 U/min with lactic acid of 11.1 mmol/L. Repeat infectious workup including respiratory cultures grew extended-spectrum beta-lactamases Enterobacter cloacae for which meropenem was initiated and blood cultures grew budding yeast and intravenous micafungin was started. Further speciation identified Saccharomyces cerevisiae and amphotericin B and flucytosine were initiated. Additional history obtained from the family revealed patient was drinking expired probiotic shakes at home. Patient completed a 2-week course with clinical improvement. Discussion: Immune dysfunction in cirrhosis increases the risk of fungemia due to malnutrition altering metabolism, impaired synthetic function, decreased immune surveillance, and systemic inflammation. S. cerevisiae, found in probiotic supplements, is emerging in immunocompromised patients and is linked to worse outcomes than infection with the more common S. boulardii. Though marketed for gut health, these products pose significant risks to immunocompromised patients. Diagnosis can be difficult as Saccharomyces invasive infections present almost identically to invasive candidiasis. Key diagnostic tools include fungal markers, cultures, BAL, and biopsy. As demonstrated in this case, thorough history taking, awareness of sub-population susceptibility and early diagnosis are critical, as fungal infections can increase mortality.