Cryptococcus Peritonitis as a Complication of Orthotopic Hepatitis C-Positive Liver Transplantation: A Case Report

Introduction: Patients who undergo liver transplantation are at risk of opportunistic infections. We present a case of a middle-aged male status post orthotopic liver transplantation complicated by subsequent cryptococcal peritonitis. Case Description/Methods: A 55-year-old man with a history of alcoholic cirrhosis complicated by ascites and hepatorenal syndrome, status post orthotopic liver transplantation from a hepatitis C-positive donor who was declared brain dead. The patient receives thymoglobulin induction and transitions to mycophenolate 500 mg twice daily with prednisone taper and tacrolimus. The patient is admitted to the hospital due to a severe headache and sudden rise in alkaline phosphatase from 139 to 707. At this time, a positive cryptococcus neoformans result returned from intraoperative peritoneal culture. Lumbar puncture with cryptococcal antigen, serum antigen, India ink stain, opening pressure and fungal culture are negative for neurologic involvement. The patient is started on intravenous amphotericin B 410 mg daily. The patient complains of sudden onset severe left sided flank pain and amphotericin B is discontinued. He is started on fluconazole 1200 mg q 24 hours. MRI shows a peri-hepatic hematoma, but no biliary obstruction, and alkaline phosphatase had decreased to 254, resulting in the patient’s discharge. Transplant and infectious disease recommends a course of fluconazole 400 mg per oral daily for at least 1 year, along with atovaquone 1500 mg daily for 6 months. At his most recent clinic visit (four months after admission), the patient now feels generally well, but has occasional headaches. His alkaline phosphatase and other liver function tests have returned to within normal range, and he continues to have medication levels monitored. Discussion: Patients undergoing liver transplant should have intraoperative ascitic fluid tested for opportunistic infections. Post-transplant immunosuppression may worsen the prognosis of patients with these infections. As a result, it is imperative to manage immunosuppression along with prophylactic therapies for opportunistic infections.