Intracranial invasive mycosis mimicking hepatic encephalopathy in a patient with cirrhosis.

Abstract

A 45-year-old man with alcohol-related decompensated cirrhosis presented with jaundice, fever, headache and altered sensorium. At presentation, he had tachycardia, disorientation to time and place, asterixis, icterus and upgoing plantar response. Investigations showed anaemia, thrombocytopenia, leucocytosis, hyperbilirubinemia and elevated arterial ammonia. Despite management with antihepatic coma measures and normalisation of ammonia, broad-spectrum antibiotics, 20% albumin, the patient worsened. On day 3, the patient developed generalised tonic-clonic seizure prompting mechanical ventilation. Examination showed right proptosis, chemosis and pupillary anisocoria. MRI brain showed multifocal infarcts in the right temporal lobe, right cerebellum and brainstem with inflammation in the right orbit, infratemporal fossa with right internal carotid artery thrombosis, and suspicious maxillary sinus thickening. Nasal scrapings showed aseptate fungal hyphae and serum galactomannan index was positive. Despite receiving liposomal amphotericin-B, patient had an unfavourable outcome. Intracranial invasive mycosis can mimic hepatic encephalopathy and is associated with high mortality in cirrhotics. A high index of suspicion, positive biomarkers and diagnostic radiology may provide the key to the diagnosis.

• Authors: Akash Roy, Nipun Verma, Chirag Kamal Ahuja
• Journal: BMJ case reports (BMJ Case Rep) Vol. 12 Issue 11 (Nov 26 2019) ISSN: 1757-790X [Electronic] England
• PMID: 31776153 (Publication Type: Case Reports, Journal Article)
• Copyright: © BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.

Topics

• Brain Diseases (complications, diagnosis, microbiology)
• Central Nervous System Fungal Infections (complications, diagnosis)
• Diagnosis, Differential
• Hepatic Encephalopathy (diagnosis)
• Humans
• Invasive Fungal Infections (complications, diagnosis)
• Liver Cirrhosis (complications)
• Male
• Middle Aged