S5555 A Rare Case of Disseminated Cryptococcosis in a Patient With Cirrhosis

Introduction: Cryptococcal infections have been widely documented after liver transplant. However, cryptococcal infections are less commonly described in patients with cirrhosis prior to transplant. Case Description/Methods: A 61-year-old man with a history of alpha-1 anti-trypsin deficiency and decompensated cirrhosis status post transjugular intrahepatic portosystemic shunt (TIPS) presented with fatigue, dyspnea, abdominal distension, and lower extremity swelling. On exam, he had a distended abdomen, 2+ bilateral lower extremity edema, supple neck, and decreased breath sounds on right side. He was afebrile and hemodynamically stable on 2 L of oxygen at presentation with labs notable for white blood cell count 8.2, Na 131, Cr 1.36 (baseline 0.8); Model for End-Stage Liver Disease (MELD) 3.0 of 26 on presentation. Abdominal ultrasound showed patent TIPS with elevated velocities ranging from 209 to 219 cm/s. Chest x-ray showed moderate size right pleural effusion. Paracentesis and thoracentesis were negative for SBP/SBE with 87 PMN cells/mm3 and 240 PMN cells/mm3, respectively. Given his underlying decompensation, a liver transplant evaluation was initiated. Three days after admission, blood cultures from admission grew Cryptococcus neoformans, and he reported a lingering headache. Fluid cultures from ascitic fluid, pleural fluid, and cerebrospinal fluid from a subsequent lumbar puncture all grew Cryptococcus. He was treated with amphotericin B and flucytosine. Hospital course was complicated by renal failure requiring hemodialysis and worsening hepatic function with a MELD 3.0 of 38 13 days after admission. He transitioned to comfort care and died 14 days after admission. Discussion: Cryptococcal infections are classically associated with immunocompromised patients such as liver transplant recipients. However, decompensated cirrhosis itself also causes immune dysfunction due to significant changes in innate immunity, adaptive immunity, and the barrier function of the intestines. Patients with cirrhosis are at an increased risk for cryptococcal infections, and decompensated cirrhosis is a risk factor for progression of cryptococcal infection to disseminated disease. Clinical presentations of disseminated cryptococcal infection are variable and symptoms are often subacute. In our case, the patient’s symptoms and subsequent decompensation were likely secondary to disseminated cryptococcosis. Clinicians should retain a high index of suspicion for infections, including cryptococcal infections, in patients with decompensated cirrhosis even if other factors are present which may explain their presentation.