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Cryptococcal meningitis in cirrhotics
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
results in better yield. Patients presenting with abdominal pain, fever or encephalopathy, high blood counts, high creatinine, low sodium, low ascitic fluid protein should be suspected of having SBP.
Conclusions: Incidence of SBP was 22.94%. Patients with nosocomial SBP had worse prognosis than community acquired SBP. Six month mortality was 51.8%. E. coli was the commonest causative organism.
Corresponding author. Harshad Vinay Joshi. E-mail: [email protected]
Corresponding author. Girisha Balaraju. E-mail: [email protected]
INCIDENCE COURSE AND OUTCOME IN COMMUNITY ACQUIRED AND NOSOCOMIAL SPONTANEOUS BACTERIAL PERITONITIS IN PATIENTS WITH CIRRHOSIS
CRYPTOCOCCAL MENINGITIS IN CIRRHOTICS
St John's Medical College Hospital, Bangalore, India
Background and Aims: To determine the Incidence, clinical, laboratory characteristics and outcome of cirrhotic patients with Spontaneous bacterial peritonitis (SBP). We also aimed to study the characteristics of community acquired vs. nosocomial SBP. Methods: We carried out a prospective single center study in St John's medical college hospital, Bangalore, between august 2010 to august 2012. Results: Of the 150 patients, 162 episodes of SBP were analyzed. Total number of cirrhotic ascites during the same period was 706. Incidence of SBP is 22.94%. Of the 162 episodes, 126(77.8%) were culture negative neutrocytic ascites (CNNA), 33(20.4%) were SBP and 3(1.8%) were monobacterial bacterascites. One hundred and forty one (87.03%) were community acquired and 21(12.97%) were nosocomial. We defined nosocomial SBP as patients developing SBP after 48 hours of hospital admission. The mean age was 48.4 +/ 14 years, 86.4% were males. Ethanol was the commonest etiology (58%), followed by cryptogenic cirrhosis (17.3%). Patients with nosocomial infections had higher incidence of past history of encephalopathy (23.8% vs. 9.2%), higher endoscopic interventions preceding admission (38% vs. 7%), paracentesis (57% Vs 12%) and higher mortality (76.2% vs. 51%) compared to community acquired SBP. Seventy five percent of patients were CTP class C. Mortality was 51.8% (84) at 6 months. Patients who died were older (mean age of 51.9 +/ 13 vs. 45.2 +/ 14.5), had encephalopathy (57.6% vs. 17.6%), elevated serum creatinine (1.35 vs. 1.2) and lower serum sodium (126.9 +/ 7.4 vs. 131 +/ 5) compared to those who were alive. Ascitic Fluid culture positivity was demonstrated in 22.2%. E. coli was the commonest organism isolated (56%) followed by Klebsiella (13.3%).
1 Department of Gastroenterology and Hepatology, Belle Vue Clinic, Kolkata, India, 2MP Birla Institute of Fundamental Research, India, 3 Department of Neurology, Belle Vue Clinic, Kolkata, India
Cryptococcal meningitis is an uncommon disease which infects HIV positive or immunocompromised patients. It is even rarer in cirrhotics .We report four non HIV, cirrhotic patients, seen over a period of one year in a single center, with Cryptococcal meningitis, who had varied clinical presentations. Cerebrospinal fluid (CSF) samples from cirrhotic patients, presenting with fever and neurological symptoms were sent for Gram stain, AFB stain, India ink examination, cryptococcal antigen detection , aerobic , fungal culture and biochemistry . Cryptococcal antigen was detected and India ink examination showed spherical yeast like organisms with a clear halo in four samples. Two of the samples also grew Cryptococcus neoformans in culture. All the four positive cases were males in the age group of 38–65 yrs. Two patients had alcoholic cirrhosis (child's A and C) and other two had HCV cirrhosis (Child's C) and cryptogenic cirrhosis (Child's B). The clinical presentation was different in each patient. Only one patient had neck stiffness, others presented with hemiplegia, vertigo and headache and hepatic encephalopathy like picture. Inspite of appropriate treatment only two patients survived. Treatment of cirrhotics with Cryptococcal meningitis presents special problems. Drug toxicity with amphotericin and fluconazole limit their use. A high index of clinical suspicion, per forming India ink examination and antigen studies on the CSF in cirrhotics with neurological symptoms and subtle fever, aids in diagnosis. Cirrhotics, due to defective chemotaxis, reduced level of complement and opsonins are at a higher risk for fungal infections. Cryptococcal meningitis should be considered in the growing spectrum of infections in cirrhotics and treatment can be challenging. Corresponding author. Manoj Agarwal. E-mail: [email protected]
Journal of Clinical and Experimental Hepatology | March 2013 | Vol. 3 | No. 1S | S82–S100
S85
Cirrhosis & Complications
Girisha Balaraju, Adarsh Channagiri Krishnamurthy, Mallikarjun Patil, Keyur Ashok Sheth, Ravikiran Sindhuvalada Karnam, Aradhya Hiriyannaiah Venu, Harshad Devarbhavi
Manoj Agarwal,1 Anuradha Agarwal,2 Sidhartha Kumar Biswas3
results in better yield. Patients presenting with abdominal pain, fever or encephalopathy, high blood counts, high creatinine, low sodium, low ascitic fluid protein should be suspected of having SBP.
Conclusions: Incidence of SBP was 22.94%. Patients with nosocomial SBP had worse prognosis than community acquired SBP. Six month mortality was 51.8%. E. coli was the commonest causative organism.
Corresponding author. Harshad Vinay Joshi. E-mail: [email protected]
Corresponding author. Girisha Balaraju. E-mail: [email protected]
INCIDENCE COURSE AND OUTCOME IN COMMUNITY ACQUIRED AND NOSOCOMIAL SPONTANEOUS BACTERIAL PERITONITIS IN PATIENTS WITH CIRRHOSIS
CRYPTOCOCCAL MENINGITIS IN CIRRHOTICS
St John's Medical College Hospital, Bangalore, India
Background and Aims: To determine the Incidence, clinical, laboratory characteristics and outcome of cirrhotic patients with Spontaneous bacterial peritonitis (SBP). We also aimed to study the characteristics of community acquired vs. nosocomial SBP. Methods: We carried out a prospective single center study in St John's medical college hospital, Bangalore, between august 2010 to august 2012. Results: Of the 150 patients, 162 episodes of SBP were analyzed. Total number of cirrhotic ascites during the same period was 706. Incidence of SBP is 22.94%. Of the 162 episodes, 126(77.8%) were culture negative neutrocytic ascites (CNNA), 33(20.4%) were SBP and 3(1.8%) were monobacterial bacterascites. One hundred and forty one (87.03%) were community acquired and 21(12.97%) were nosocomial. We defined nosocomial SBP as patients developing SBP after 48 hours of hospital admission. The mean age was 48.4 +/ 14 years, 86.4% were males. Ethanol was the commonest etiology (58%), followed by cryptogenic cirrhosis (17.3%). Patients with nosocomial infections had higher incidence of past history of encephalopathy (23.8% vs. 9.2%), higher endoscopic interventions preceding admission (38% vs. 7%), paracentesis (57% Vs 12%) and higher mortality (76.2% vs. 51%) compared to community acquired SBP. Seventy five percent of patients were CTP class C. Mortality was 51.8% (84) at 6 months. Patients who died were older (mean age of 51.9 +/ 13 vs. 45.2 +/ 14.5), had encephalopathy (57.6% vs. 17.6%), elevated serum creatinine (1.35 vs. 1.2) and lower serum sodium (126.9 +/ 7.4 vs. 131 +/ 5) compared to those who were alive. Ascitic Fluid culture positivity was demonstrated in 22.2%. E. coli was the commonest organism isolated (56%) followed by Klebsiella (13.3%).
1 Department of Gastroenterology and Hepatology, Belle Vue Clinic, Kolkata, India, 2MP Birla Institute of Fundamental Research, India, 3 Department of Neurology, Belle Vue Clinic, Kolkata, India
Cryptococcal meningitis is an uncommon disease which infects HIV positive or immunocompromised patients. It is even rarer in cirrhotics .We report four non HIV, cirrhotic patients, seen over a period of one year in a single center, with Cryptococcal meningitis, who had varied clinical presentations. Cerebrospinal fluid (CSF) samples from cirrhotic patients, presenting with fever and neurological symptoms were sent for Gram stain, AFB stain, India ink examination, cryptococcal antigen detection , aerobic , fungal culture and biochemistry . Cryptococcal antigen was detected and India ink examination showed spherical yeast like organisms with a clear halo in four samples. Two of the samples also grew Cryptococcus neoformans in culture. All the four positive cases were males in the age group of 38–65 yrs. Two patients had alcoholic cirrhosis (child's A and C) and other two had HCV cirrhosis (Child's C) and cryptogenic cirrhosis (Child's B). The clinical presentation was different in each patient. Only one patient had neck stiffness, others presented with hemiplegia, vertigo and headache and hepatic encephalopathy like picture. Inspite of appropriate treatment only two patients survived. Treatment of cirrhotics with Cryptococcal meningitis presents special problems. Drug toxicity with amphotericin and fluconazole limit their use. A high index of clinical suspicion, per forming India ink examination and antigen studies on the CSF in cirrhotics with neurological symptoms and subtle fever, aids in diagnosis. Cirrhotics, due to defective chemotaxis, reduced level of complement and opsonins are at a higher risk for fungal infections. Cryptococcal meningitis should be considered in the growing spectrum of infections in cirrhotics and treatment can be challenging. Corresponding author. Manoj Agarwal. E-mail: [email protected]
Journal of Clinical and Experimental Hepatology | March 2013 | Vol. 3 | No. 1S | S82–S100
S85
Cirrhosis & Complications
Girisha Balaraju, Adarsh Channagiri Krishnamurthy, Mallikarjun Patil, Keyur Ashok Sheth, Ravikiran Sindhuvalada Karnam, Aradhya Hiriyannaiah Venu, Harshad Devarbhavi
Manoj Agarwal,1 Anuradha Agarwal,2 Sidhartha Kumar Biswas3