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Cirrhosis, gastrointestinal bleed, and cryptococcal peritonitis
Amy E Barnett1, Karen B Brust2
1Department of Internal Medicine, Baylor Scott & White Medical Center - TempleTempleTexas.
Insights
Cryptococcus neoformans peritonitis is rare in non-HIV patients but affects those with cirrhosis. Early diagnosis using peritoneal fluid cryptococcal antigen testing is crucial, as mortality remains high despite treatment.
Area of Science:
- Infectious Diseases
- Hepatology
- Critical Care Medicine
Background:
- Disseminated Cryptococcus neoformans infection is uncommon in non-HIV patients but can manifest as peritonitis, particularly in individuals with cirrhosis.
- Diagnostic delays and high mortality rates are associated with cryptococcal peritonitis in this population.
Purpose of the Study:
- To review and analyze cases of cryptococcal peritonitis in HIV-negative adults with underlying cirrhosis.
- To identify risk factors, diagnostic methods, treatment strategies, and outcomes for this rare condition.
Main Methods:
- A literature search was conducted to identify proven cases of cryptococcal peritonitis in HIV-negative cirrhotic adults.
- Demographic, clinical, diagnostic, treatment, and outcome data were collected and analyzed, including a case from the authors' institution.
Main Results:
- Twenty-one cases were identified, predominantly affecting men, with alcohol abuse being the leading cause of cirrhosis.
- Upper gastrointestinal bleeding preceded peritonitis in 38% of patients. Peritoneal fluid analysis often showed lymphocytic predominance, and half of the patients had fungemia.
- Peritoneal fluid cryptococcal antigen testing was positive in all tested cases, and Amphotericin B was the primary treatment, with a high mortality rate of 76%.
Conclusions:
- Cryptococcus neoformans is an opportunistic pathogen causing peritonitis in non-HIV cirrhotic patients, with recent upper gastrointestinal bleeding being a potential risk factor.
- Suspicion of cryptococcal infection is warranted in cirrhotic patients presenting with spontaneous bacterial peritonitis symptoms, especially with lymphocytic-predominant ascites and negative bacterial cultures.
- Peritoneal fluid cryptococcal antigen testing can expedite diagnosis, but mortality remains high despite standard treatment with Amphotericin B.
Abstract:
Disseminated Cryptococcus neoformans infection rarely causes peritonitis in non-HIV-infected patients but does affect cirrhotic patients. Diagnostic challenges delay treatment, and mortality is high. We performed a literature search of proven cryptococcal peritonitis cases in HIV-negative adults with underlying cirrhosis, included our own case, and collected demographic, infection risk factor, diagnostic, treatment, and outcomes data. We identified 16 articles and 21 cases. Most patients were men. Alcohol abuse was the leading cause of underlying cirrhosis (n = 10, 48%). Eight (38%) patients experienced an upper gastrointestinal bleed (UGIB) within a month before peritonitis presentation. Peritoneal fluid analysis was abnormal and lymphocytic predominant. Half the patients were fungemic. When performed, peritoneal fluid cryptococcal antigen (CrAg) test results were positive. Amphotericin B was the primary treatment. Mortality was high at 76%. In conclusion, C. neoformans is an opportunistic pathogen that causes peritonitis in non-HIV, cirrhotic patients. People with recent UGIB seem to be at risk. Cryptococcus species infection should be suspected in patients with clinical signs and symptoms of spontaneous bacterial peritonitis whose lymphocytic-predominant peritoneal fluid and cultures are negative for bacterial growth. Peritoneal CrAg testing expedites diagnosis because growth on fungal media is slow. Mortality remains high, despite standard therapy with amphotericin B.
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