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Transudative pleural effusion as an initial presentation of a disseminated cryptococcosis infection in a HIV-negative patient with cirrhosis. Med Mycol Case Rep 2021; 34:18-21. [PMID: 34557378 PMCID: PMC8446742 DOI: 10.1016/j.mmcr.2021.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/20/2021] [Accepted: 08/31/2021] [Indexed: 12/18/2022] Open
Abstract
To our knowledge, this is the first case report of a transudative pleural effusion with positive Cryptococcal antigen and culture. We describe a 32-year-old male with end-stage liver disease (ESLD) who presented to an outside hospital with dyspnea and a large pleural effusion. An initial pleural fluid analysis was positive for Cryptococcal Ag. However, the infection was eventually found to be widespread as he had positive Cryptococcal Ag and cultures in his pleural fluid, serum, and cerebrospinal fluid (CSF). His antimicrobial regiment was escalated from fluconazole to amphotericin B and flucytosine. His medical condition deteriorated, and the patient passed away. Due to its rarity and range of clinical severity, diagnosis of disseminated Cryptococcosis can be delayed. We present this case to bring awareness of this diagnosis as a differential in immunocompromised patients regardless of a transudative pleural effusion.
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Ferreira da Silva AC, Cunha-Silva M, Ferraz Mazo D, Mana MF, Vicente de Paula R, de Ataíde EC, Boin IDFSF, Stucchi RSB, Sevá-Pereira T. Cryptococcal peritonitis in patients on the liver transplant waitlist: Reporting two cases with opposite outcomes. Transpl Infect Dis 2021; 23:e13583. [PMID: 33583111 DOI: 10.1111/tid.13583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 02/02/2021] [Accepted: 02/07/2021] [Indexed: 11/30/2022]
Abstract
Cryptococcus neoformans is rarely associated with peritonitis in cirrhotic patients; nevertheless, it has a high mortality rate. Early diagnosis and prompt treatment may be the determining prognostic factors. This is a report of two patients awaiting a liver transplant who had opposite outcomes after the diagnosis of spontaneous cryptococcal peritonitis. In Patient 1, the fungal culture was positive in the blood and ascites. She had a poor evolution and died, which was likely caused by the delayed diagnosis and concomitant bacterial infections. In Patient 2, the fungus was found in the ascites, urine, and cerebrospinal fluid cultures. Antifungal treatment was effective. He underwent a liver transplant on the 83rd day of antifungal therapy and is still alive 1 year later. It is important to suspect fungal etiology when there is a lack of response to antibiotics in patients with decompensated cirrhosis and spontaneous peritonitis, and physicians must be aware of leukocyte count in the ascitic fluid, which is not so high in these cases. This report also emphasizes the need for the routine use of blood culture bottles for microbiological analysis of the ascitic fluid, as it was helpful to diagnose fungal peritonitis in both cases.
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Affiliation(s)
| | - Marlone Cunha-Silva
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil.,Unit of Liver Transplantation, Hospital de Clinicas, University of Campinas (Unicamp), Campinas, Brazil
| | - Daniel Ferraz Mazo
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | - Mauy Frujuello Mana
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil
| | | | - Elaine Cristina de Ataíde
- Unit of Liver Transplantation, Hospital de Clinicas, University of Campinas (Unicamp), Campinas, Brazil.,Department of Surgery, University of Campinas (Unicamp), Campinas, Brazil
| | - Ilka de Fátima Santana Ferreira Boin
- Unit of Liver Transplantation, Hospital de Clinicas, University of Campinas (Unicamp), Campinas, Brazil.,Department of Surgery, University of Campinas (Unicamp), Campinas, Brazil
| | - Raquel Silveira Bello Stucchi
- Unit of Liver Transplantation, Hospital de Clinicas, University of Campinas (Unicamp), Campinas, Brazil.,Division of Infectious Diseases, University of Campinas (Unicamp), Campinas, Brazil
| | - Tiago Sevá-Pereira
- Division of Gastroenterology (Gastrocentro), University of Campinas (Unicamp), Campinas, Brazil.,Unit of Liver Transplantation, Hospital de Clinicas, University of Campinas (Unicamp), Campinas, Brazil
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3
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Cryptococcosis in Liver Transplant Candidates and Recipients. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00399-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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4
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Barnett AE, Brust KB. Cirrhosis, gastrointestinal bleed, and cryptococcal peritonitis. Proc (Bayl Univ Med Cent) 2020; 33:195-198. [PMID: 32313460 DOI: 10.1080/08998280.2020.1723361] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 01/16/2020] [Accepted: 01/27/2020] [Indexed: 01/31/2023] Open
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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Affiliation(s)
- Amy E Barnett
- Department of Internal Medicine, Baylor Scott & White Medical Center - TempleTempleTexas
| | - Karen B Brust
- Division of Infectious Diseases, Department of Internal Medicine, Baylor Scott & White Medical Center - TempleTempleTexas
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5
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Kandula M, Kelkar AH, Liberio N, Aiyer MK. Cryptococcemia in an HIV-negative patient with decompensated liver cirrhosis. J Community Hosp Intern Med Perspect 2016; 6:33383. [PMID: 27987289 PMCID: PMC5161803 DOI: 10.3402/jchimp.v6.33383] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 10/30/2016] [Accepted: 11/10/2016] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Cryptococcal infections have been mostly associated with immunocompromised individuals, 80-90% of whom have been HIV-positive patients. Increasingly, cryptococcal infections are being reported in cirrhotic patients who are HIV-negative. The underlying immunologic defects in cirrhotic patients seem to play an important role in predisposing them to cryptococcosis and affecting their morbidity and mortality. CASE PRESENTATION We present a case of disseminated cryptococcosis in an HIV-negative patient with underlying cirrhosis, who had rapid worsening of his hyponatremia with renal failure and was unable to recover, despite aggressive measures. CONCLUSION Cryptococcus is a more common culprit of infections seen in cirrhotic patients than what it was previously known, and a high index of suspicion is required to diagnose these patients. Identification of poor prognostic factors, early diagnosis and intervention is crucial in the management of these patients.
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Affiliation(s)
- Manasa Kandula
- Division of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL, USA;
| | - Amar H Kelkar
- Division of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Nicole Liberio
- Division of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Meenakshy K Aiyer
- Division of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
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6
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Majeed A, Ullah W, Zahid U, Al Mohajer M. Persistent spontaneous fungal peritonitis secondary to Candida albicans in a patient with alcoholic cirrhosis and review of the literature. BMJ Case Rep 2016; 2016:bcr-2016-216979. [PMID: 27873750 DOI: 10.1136/bcr-2016-216979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Candida albicans is a common human pathogen. Occasionally, it can cause peritonitis in immunocompromised and postsurgical patients. We report a case of a male patient who presented with abdominal pain and distention. He had a history of end-stage liver disease secondary to alcoholism. His peritoneal fluid culture revealed C albicans, and (1-3)-β-d glucan (BDG) level was elevated. His hospital course was complicated by sepsis and renal failure. He was treated with antifungals for spontaneous fungal peritonitis. Fungal peritonitis should be suspected in patients with chronic liver disease particularly with elevated BDG levels.
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Affiliation(s)
- Aneela Majeed
- Division of Infectious Disease, Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Waqas Ullah
- Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Umar Zahid
- Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Mayar Al Mohajer
- Division of Infectious Disease, Department of Medicine, University of Arizona, Tucson, Arizona, USA
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Spies FS, de Oliveira MB, Krug MS, Severo CB, Severo LC, Vainstein MH. Cryptococcosis in patients living with hepatitis C and B viruses. Mycopathologia 2014; 179:307-12. [PMID: 25528539 DOI: 10.1007/s11046-014-9843-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 11/27/2014] [Indexed: 12/22/2022]
Abstract
Cryptococcosis, a systemic fungal infection, has become a significant, global public health problem. Patients with liver disease have an increased predisposition to infections, such as Cryptococcosis. To report the underlying disease, the variety of etiologic agents involved and the outcomes of the Cryptococcosis in patients living with HBV and/or HCV, we reviewed 34 medical records of patients who were diagnosed with Cryptococcosis by the Mycology Laboratory of Santa Casa Hospital, Porto Alegre, Brazil. Males corresponded to 79% of the patients, and the average patient age was 46.9 years. The cultures of 26/34 patients were positive: 25 patients were infected with Cryptococcus neoformans and one with C. gattii. A total of 14 deaths (41%) occurred. As a criterion of our study, all patients had viral hepatitis infection: 27 (80%) were infected with HCV, five (15%) were infected with HBV, and two patients were infected with both viruses. Because HBV and/or HCV are transmitted among drug users through infected blood, and the end-stage cirrhotic liver must be transplanted, these two population types were well represented in this study and were analyzed in detail. Cryptococcosis patients living with HCV and/or HBV appear to have the same symptoms, mean age and gender distribution as the general Cryptococcosis population. Once Cryptococcosis affects the brain, a high mortality rate ensues; therefore, physicians must be aware of the possible occurrence of this disease in patients living with HCV and HBV.
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Affiliation(s)
- Fernanda Sá Spies
- Centro de Biotecnologia, Universidade Federal do Rio Grande do Sul, Avenida Bento Gonçalves 9500, 43421, Setor 4, Porto Alegre, RS, 91501-970, Brazil,
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Bal CK, Bhatia V, Khillan V, Rathor N, Saini D, Daman R, Sarin SK. Spontaneous cryptococcal peritonitis with fungemia in patients with decompensated cirrhosis: Report of two cases. Indian J Crit Care Med 2014; 18:536-9. [PMID: 25136195 PMCID: PMC4134630 DOI: 10.4103/0972-5229.138161] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Cryptococcus neoformans is encapsulated yeast that predominately infects immunocompromised individuals. Liver disease is an under-recognized predisposition for cryptococcal disease. We report two nonalcoholic, nondiabetic, and human immunodeficiency virus - negative cirrhotic patients, with spontaneous cryptococcal peritonitis. Cryptococcus infection was diagnosed by culture of ascitic fluid and peripheral blood in both. We treated the first patient with amphotericin-B, but he expired. The second patient with earlier diagnosis, survived to discharge with fluconazole treatment. We suggest a high clinical suspicion for Cryptococcus as a possible etiology of spontaneous peritonitis in cirrhotic patients.
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Affiliation(s)
- Chinmaya Kumar Bal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vikram Bhatia
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vikas Khillan
- Department of Microbiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Neha Rathor
- Department of Microbiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Deepak Saini
- Department of Critical Care Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ripu Daman
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Hwang SY, Yu SJ, Lee JH, Kim JS, Yoon JW, Kim YJ, Yoon JH, Kim EC, Lee HS. Spontaneous fungal peritonitis: a severe complication in patients with advanced liver cirrhosis. Eur J Clin Microbiol Infect Dis 2013; 33:259-64. [DOI: 10.1007/s10096-013-1953-2] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023]
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Alexopoulou A, Papadopoulos N, Eliopoulos DG, Alexaki A, Tsiriga A, Toutouza M, Pectasides D. Increasing frequency of gram-positive cocci and gram-negative multidrug-resistant bacteria in spontaneous bacterial peritonitis. Liver Int 2013; 33:975-81. [PMID: 23522099 DOI: 10.1111/liv.12152] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 02/22/2013] [Indexed: 02/13/2023]
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is historically caused by Gram-negative bacteria (GNB) almost exclusively Enterobacteriaceae. Recently, an increasing rate of infections with Gram-positive cocci (GPC) and multidrug-resistant (MDR) microorganisms was demonstrated. AIMS To assess possible recent changes of the bacteria causing SBP in cirrhotic patients. METHODS We retrospectively recorded 47 cases (66% males) during a 4-year-period (2008-2011). RESULTS Twenty-eight (60%) patients had healthcare-associated infections while 15 (32%) received prophylactic quinolone treatment. GPC were found to be the most frequent cause (55%). The most prevalent organisms in a descending order were Streptococcus spp (n = 10), Enterococcus spp (n = 9), Escherichia coli (n = 8), Klebsiella pneumonia (n = 5), methicillin-sensitive Staphylococcus aureus (n = 4) and coagulase-negative Staphylococcus spp (n = 3). Nine of the isolated bacteria (19%) were MDR, including carbapenemase-producing K. pneumonia (n = 4), followed by extended-spectrum beta-lactamase-producing E. coli (n = 3) and Pseudomonas aeruginosa (n = 2). MDR bacteria were more frequently isolated in healthcare-associated than in community-acquired infections (100% vs 50%, P = 0.006), in patients receiving long-term quinolone prophylaxis (67% vs 24%, P = 0.013) and in those with advanced liver disease as suggested by higher MELD score (28 vs 19, P = 0.012). More infections with GNB than GPC were healthcare-associated (81% vs 42%, P = 0.007). Third-generation cephalosporin resistance was observed in 49% and quinolone resistance in 47%. CONCLUSIONS GPC were the most frequent bacteria in culture-positive SBP and a variety of drug-resistant microorganisms have emerged. As a result of high rates of resistance in currently recommended therapy and prophylaxis, the choice of optimal antibiotic therapy is vital in the individual patient.
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El-Kersh K, Rawasia WF, Chaddha U, Guardiola J. Rarity revisited: cryptococcal peritonitis. BMJ Case Rep 2013; 2013:bcr-2013-009099. [PMID: 23845672 DOI: 10.1136/bcr-2013-009099] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cryptococcal peritonitis is a rare disease. Although the respiratory tract is considered to be the usual port of entry for the organism, the gastrointestinal tract can also serve as the potential site of entry. Here, we present a case of cryptococcal peritonitis that developed in an HIV-negative patient with underlying liver cirrhosis. We reviewed the literature and a total of 61 cases of cryptococcal peritonitis were identified. Liver cirrhosis, HIV/AIDS and end-stage renal disease on continuous ambulatory peritoneal dialysis were the major risk factors for developing crytococcal peritonitis.
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Affiliation(s)
- Karim El-Kersh
- Department of Pulmonary, Critical Care & Sleep Medicine, University of Louisville, Louisville, Kentucky, USA.
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12
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Pastagia M, Caplivski D. Disseminated cryptococcosis resulting in miscarriage in a woman without other immunocompromise: a case report. Int J Infect Dis 2009; 14:e441-3. [PMID: 19682936 DOI: 10.1016/j.ijid.2009.05.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Accepted: 05/31/2009] [Indexed: 11/28/2022] Open
Abstract
We present an unusual case of disseminated cryptococcosis involving the lungs, placenta, and gall bladder in an apparently immunocompetent pregnant woman. The infection resulted in spontaneous abortion. The patient's condition only improved after cholecystectomy and several weeks of antifungal therapy. An in-depth evaluation revealed no central nervous system involvement or immunocompromising condition other than pregnancy.
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Affiliation(s)
- Mina Pastagia
- Division of Infectious Diseases, Department of Internal Medicine, Mount Sinai School of Medicine, 1 Gustave L. Levy Place, New York, NY 10029, USA.
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Abstract
BACKGROUND Invasive candidiasis (IC) is associated with significant morbidity and mortality in critically ill patients. This, in conjunction with difficulties in diagnosis, underscores the need for novel treatment strategies based on the identification of significant risk factors for IC. OBJECTIVE To review the evidence surrounding the use of early antifungals in critically ill adult patients and to present concise and specific recommendations for different early treatment strategies for IC. DATA SOURCES AND DATA EXTRACTION Pubmed search from 1966 to July 2008 using the search terms "antifungals, critical care, prophylaxis, preemptive therapy, and empiric therapy." Examined all relevant peer-reviewed original articles, meta-analyses, guidelines, consensus statements, and review articles. CONCLUSION The use of early antifungal therapy should be reserved for patients with a high risk (10% to 15%) of developing IC. Despite a large number of articles published on this topic, there is no single predictive rule that can adequately forecast IC in critically ill patients. Until further prospective validation of existing data is completed, clinicians should assess patients on a case-by-case basis and determine the need for early antifungal treatment strategies based on frequent evaluations of risk factors and clinical status.
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Park WB, Choe YJ, Lee KD, Lee CS, Kim HB, Kim NJ, Lee HS, Oh MD, Choe KW. Spontaneous cryptococcal peritonitis in patients with liver cirrhosis. Am J Med 2006; 119:169-71. [PMID: 16443429 DOI: 10.1016/j.amjmed.2005.06.070] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2004] [Accepted: 06/30/2005] [Indexed: 12/20/2022]
Affiliation(s)
- Wan Beom Park
- Department of Internal Medicine, Seoul National University, College of Medicine, Seoul, Republic of Korea
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Abstract
The objective of the present study was to report on three distinct forms of presentation of Cryptococcus neoformans infection in three cirrhotic patients. One patient had disseminated cryptococcosis with detection of the fungus in ascitic fluid, cerebrospinal fluid and blood; the second patient had pleural involvement and the third had cutaneous infection caused by C. neoformans.
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Affiliation(s)
- Alex Vianey Callado França
- Hepatology Unit, Division of Gastroenterology, Medical School of Ribeirão Preto, São Paulo University, São Paulo, Brazil.
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Singh N, Husain S, de Vera M, Gayowski T, Cacciarelli TV. Cryptococcus neoformans Infection in Patients With Cirrhosis, Including Liver Transplant Candidates. Medicine (Baltimore) 2004; 83:188-192. [PMID: 15118545 DOI: 10.1097/01.md.0000126760.45299.69] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
We reviewed the cases of patients with cirrhosis, including liver transplant candidates, at our institution in the last 3 years (n = 5) and those individually described in the literature (n = 28), to assess unique characteristics and outcome of cryptococcosis in these patients. Sixty-four percent (21/33) of the patients had no other recognized immunosuppression. Peritonitis (in 45%, 15/33 of the patients) with modest pleocytosis in the ascitic fluid, was the most common presenting feature. Median time to detection of Cryptococcus in the ascitic fluid cultures was 6 days. Overall mortality rate was 81% (26/32); death was deemed attributable to cryptococcosis in 24/26 patients who died. Evaluation of culture-negative neutrocytic ascites in febrile cirrhotic patients warrants consideration of cryptococcal peritonitis.
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Affiliation(s)
- Nina Singh
- From Veterans Affairs Medical Center and University of Pittsburgh Medical Center, Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania
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Berzsenyi MD, Broughton SJ, Herrmann R, Merrett MN. Spontaneous fungal peritonitis in a hemochromatotic patient with cirrhosis on long-term prophylactic antibiotics. J Gastroenterol Hepatol 2004; 19:474-5. [PMID: 15012794 DOI: 10.1111/j.1440-1746.2003.03354.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Samonakis DN, Chatzicostas C, Vardas E, Roussomoustakaki M, Kouroumalis EA. Increased incidence of fungal infections in advanced primary biliary cirrhosis. J Clin Gastroenterol 2003; 36:369. [PMID: 12642749 DOI: 10.1097/00004836-200304000-00019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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