Ting Peng-Sheng, Agarwalla Anant, Woreta Tinsay A
School of Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA.
Division of Gastroenterology/Hepatology, The Johns Hopkins Hospital, Baltimore, MD, USA.
J Clin Transl Hepatol. 2019 Jun 28;7(2):191-193. doi: 10.14218/JCTH.2019.00005. Epub 2019 May 4.
In the non-human immunodeficiency virus infected population, cryptococcosis occurs primarily in people who are functionally immunosuppressed, including patients who have undergone solid organ transplantation requiring immunosuppressive medications, are on corticosteroids, or have renal failure or cirrhosis. Cryptococcal meningitis poses a particular challenge in the setting of cirrhosis because its clinical presentation can mimic hepatic encephalopathy. Here, we describe two patients with decompensated cirrhosis, both with a known history of hepatic encephalopathy who had lumbar punctures and were found to have cryptococcal meningitis. The first patient had a subacute fluctuating change in mental status, while the second patient had progressive subacute headaches, gait disturbance, and hearing loss. Both patients were treated with amphotericin B and flucytosine induction, but only the second survived to maintenance therapy. These cases demonstrate the importance of having a high index of suspicion for cryptococcal meningitis in cirrhosis and having a low threshold for performing a lumbar puncture when altered mental status or other neurologic complaints are not fully explained by hepatic encephalopathy. We also provide a brief review of the pathobiology of cryptococcal infection in cirrhosis and highlight the challenges in therapy.
在未感染人类免疫缺陷病毒的人群中，隐球菌病主要发生在功能免疫抑制的人群中，包括接受实体器官移植且需要使用免疫抑制药物的患者、正在使用皮质类固醇的患者，或患有肾衰竭或肝硬化的患者。在肝硬化背景下，隐球菌性脑膜炎带来了特殊挑战，因为其临床表现可能类似于肝性脑病。在此，我们描述了两名失代偿期肝硬化患者，他们都有肝性脑病病史，接受了腰椎穿刺，结果发现患有隐球菌性脑膜炎。第一名患者精神状态有亚急性波动变化，而第二名患者有进行性亚急性头痛、步态障碍和听力丧失。两名患者均接受了两性霉素B和氟胞嘧啶诱导治疗，但只有第二名患者存活至维持治疗阶段。这些病例表明，对于肝硬化患者中的隐球菌性脑膜炎保持高度怀疑指数非常重要，并且当肝性脑病不能完全解释精神状态改变或其他神经系统症状时，进行腰椎穿刺的阈值要低。我们还简要回顾了肝硬化中隐球菌感染的病理生物学，并强调了治疗中的挑战。
