Cirrhosis, gastrointestinal bleed, and cryptococcal peritonitis

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.