SHM Converge Scientific Abstract ePoster Gallery-Cryptococcal Meningitis Masquerading as Hepatic Encephalopathy

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This case describes a 59-year-old man with alcoholic cirrhosis, hypertension, COPD, and diabetes who presented with 3 months of progressive confusion. Because he had a history of repeated episodes of hepatic encephalopathy, his symptoms initially seemed consistent with another encephalopathy flare and he improved only briefly with standard treatment. However, worsening neurologic findings and imaging showed extensive meningitis with abnormal enhancement in the basal ganglia and FLAIR hyperintensity in the cerebral sulci, raising concern for a more serious intracranial process.<br /><br />An infectious disease and neurology workup led to lumbar puncture and empiric broad-spectrum therapy, followed by amphotericin B when CSF results suggested fungal meningitis. Despite negative initial cryptococcal testing and other infectious studies, the patient was transferred to a tertiary center for further evaluation, including possible brain biopsy. A repeat lumbar puncture confirmed cryptococcal meningitis, demonstrating that the first diagnostic tests had been falsely negative. He was then treated with amphotericin B and flucytosine, which led to improved mental status. Serial lumbar punctures showed decreasing CSF white blood cell counts and cryptococcal titers, and he was later transitioned to prolonged fluconazole maintenance therapy.<br /><br />The case also noted unexplained hypothermia, thought possibly due to cryptococcal involvement of the adrenal glands. Overall, this report emphasizes that cryptococcal meningitis can masquerade as hepatic encephalopathy in patients with cirrhosis, and that persistent diagnostic reassessment, repeat testing, and multidisciplinary collaboration are essential when the clinical course does not fit the initial diagnosis.

Asset Subtitle

Hena Yagnik

Meta Tag

Author List Badiaa El-Imad, Charles Sonaliya, Christina Orate Dimapilis, Hena Yagnik, Kuhan Umakanthan, Otitodilichukwu Osadebe, Priyanka Batta, Reena Patel, Thong Ngo

Category Clinical Vignettes

Concept Cryptococcal Meningitis

Concept Lumbar Puncture

Concept Meningitis

Concept Amphotericin B

Concept Flucytosine

Distinguished Non-Finalist

Presenter Organization Inspira Health Network

Presenting Author Hena Yagnik

Track Adult

Keywords

cryptococcal meningitis

hepatic encephalopathy

cirrhosis

false-negative testing

lumbar puncture

amphotericin B

flucytosine

fluconazole maintenance

basal ganglia enhancement

hypothermia

Cryptococcal Meningitis

Lumbar Puncture

Meningitis

Amphotericin B

Flucytosine