Hyponatremia as the Initial Presentation of Cryptococcal Meningitis After Liver Transplantation

Abstract

Introduction:Meningoencephalitis is the most common clinical manifestation of cryptococcal infection, as the organism has a propensity to invade the CNS. Patients often present with elevated intracranial pressure, focal motor deficits, altered mentation and internal hydrocephalus. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) has been reported as a notable cause of euvolemic hyponatremia in immunocompromised patients.Case Presentation:A 67-year-old male with liver transplantation due to hepatitis C (HCV) related liver cirrhosis developed severe hyponatremia four months after liver transplantation, which was discovered during routine clinic visit. Patient was referred to the emergency department, treated and discharged with normal serum sodium level. Few days later, he presented with dizziness, confusion, ataxia, abnormal muscle movements and leg pain. Laboratory investigations were consistent with SIADH and revealed a sodium level of 115 mmol/L. Brain MRI showed a leptomeningeal enhancement in the superior cerebellar sulci suspicious for infection. Lumbar puncture was performed and consistent with Cryptococcus neoformans infection; therefore, cryptococcal meningitis was diagnosed. Amphotericin B was started for the patient for six weeks followed by fluconazole for one year. His level of consciousness improved significantly, and his serum sodium level slowly returned to its normal baseline over three weeks after starting amphotericin B.Conclusions:Symptomatic hyponatremia secondary to SIADH remains a rare complication of cryptococcal meningitis.

Orthostatic hypotension as the initial presentation of disseminated cryptococcosis in a kidney transplant recipient

“…Unusual presentations can delay diagnosis and treatment significantly. Some of the unusual presenting symptoms for cryptococcal meningitis in transplant patients include headache without neurological signs [8] , vertigo [7] , sinusitis [6] , and hyponatremia [5] . Atypical and non-specific presenting symptoms result in delayed diagnoses, exemplified by our patient who visited the emergency room several times with orthostasis and pre-syncope prior to being admitted.…”

“…Due to chronic immunosuppression, these patients can often present with non-specific and atypical signs and symptoms contributing to delayed diagnosis. Atypical (non-infectious) presenting symptoms may be more common including hyponatremia, sinusitis, and vertigo [5] , [6] , [7] . Several studies have shown that there are worse outcomes associated with cryptococcosis in transplant recipients when compared to patients living with HIV [1] , [2] , [3] , [4] .…”

Cryptococcemia in an HIV-negative patient with decompensated liver cirrhosis

“…There were a few other concerning factors that may have predicted a poor prognosis. These include acute on chronic hyponatremia, which has been reported as an early warning sign of cryptococcal meningitis (19), as well as the patient's hepatorenal syndrome which portends a poor outcome in cirrhotic patients with SBP. Our patient also had hepatitis C, which in itself downregulates the immune system to persist in the human tissue for years.…”

Cryptococcosis Cases in a University Hospital

“…Mansoor ve ark. (7) karaciğer transplantasyonu olan hastada kriptokok menenjit olgusu bildirmişlerdir. Organ nakli, lenfomalar, glukokortikoid tedavisi alan hastalar, HIV enfeksiyonu ve diğer immün yetmezlikleri kriptokok enfeksiyonu için predispozan faktörlerdir.…”