Intracranial invasive mycosis mimicking hepatic encephalopathy in a patient with cirrhosis

What is it about?

A 45-year-old male 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 up-going plantar response. Investigations showed anemia, thrombocytopenia, leukocytosis, hyperbilirubinemia and elevated arterial ammonia. Despite management with anti-hepatic-coma measures and normalization of ammonia, broad-spectrum antibiotics, 20% albumin the patient worsened. On day three the patient developed generalized tonic-clonic seizure prompting mechanical ventilation. Examination showed right proptosis, chemosis, and pupillary anisocoria.MRI brain showed multifocal infarcts in the righttemporal 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 unfavorable outcome. Conclusions: 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.

Featured Image