Hepatic Arterial Dot Signs In Isolated Small Duct Primary Sclerosing Cholangitis

Abstract

475normal white cell count (4.4 ¥ 10 9 ; NR 4.0-11.0). Sodium (136 mmol/L; NR 136-146) and potassium (4.3 mmol/L; NR 3.5-5.0) were both normal. Urea (10.9 mmol/L; NR 3.0-8.4) was mildly elevated, while the creatinine (0.09 mmol/L; NR 0.06-0.11) was normal. Liver function tests were abnormal, with an elevated bilirubin (56 mmol/L; NR 0-20), alkaline phosphatase (219 U/L; NR 30-120) and g-glutamyl transpeptidase (501 U/L; NR 10-55). However, alanine transaminase (28 U/L; NR 0-50) was normal. Hepatic synthetic function was impaired, with a mildly decreased albumin (35 g/L; NR 38-50) and total protein (61 g/L; NR 65-85) and a prolonged international normalized ratio of 1.3. Blood, feces and urine cultures taken before the commencement of antibiotics were all negative. Chest X-ray revealed minor bibasal atelectasis. Tumor markers, in particular alpha fetoprotein, were negative. The ascites was tapped, revealing green fluid of low viscosity. Gram stain of this fluid revealed small numbers of yeast cells and pseudohyphae and culture yielded a moderate growth of Candida albicans. As the specimen was clotted it was not suitable for a cell count.A diagnosis of fungal peritonitis was made. On the basis of the Gram-stain results, prior to the availability of the culture results, the patient was commenced on a 2-week course of oral fluconazole, 400 mg daily. Ceftriaxone and neomycin were ceased. There was an improvement in the patient's condition and he was subsequently discharged home. Further ascitic fluid examination was carried out at a subsequent presentation for worsening hepatic encephalopathy. The ascitic fluid examination and culture on that occasion revealed no evidence of fungal or bacterial peritonitis.Spontaneous fungal peritonitis associated with chronic liver disease and cirrhosis is a rare process, evident by the small number of case reports in the literature. 4-6 This is the first report of fungal peritonitis occurring in the setting of hemochromatosis. Long-term administration of quinolones has been shown to reduce rates of infection as a result of Enterobacteriaceae in cirrhotic patients at risk of SBP. 2 However, long-term norfloxacin administration in these patients increases the risk of severe hospitalacquired staphylococcal infections and of high-level resistance to antibiotics. 3,7 Presumably, this is the result of an alteration in gastrointestinal flora caused by exposure to antibiotics. It is possible that the longterm use of neomycin and frequent intermittent use of ceftriaxone in this patient led to a change in gastrointestinal flora, allowing for colonization with Candida albicans and subsequent development of spontaneous fungal peritonitis. The use of probiotic agents in such cases may have a potential benefit in preventing the development of spontaneous fungal peritonitis. This awaits further study. This is a rare cause of peritonitis in a cirrhotic patient, but reinforces the need to analyze the ascitic fluid on each occasion when such patients present with suspected peritonitis, particularly i...