Hyponatremia as the Initial Presentation of Cryptococcal Meningitis After Liver Transplantation.
BACKGROUND
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.


METHODS
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.
College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
Saad
S
Mansoor
College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
Hamzah
H
Juhardeen
College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
Asma
A
Alnajjar
Department of Liver and Small Bowel Transplantation and Hepatobiliary and Pancreatic Surgery, King Faisal Specialist Hospital and Research Center (KFSH and RC), Riyadh, Saudi Arabia.
Faisal
F
Abaalkhail
College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
Wael
W
Al-Kattan
Department of Liver and Small Bowel Transplantation and Hepatobiliary and Pancreatic Surgery, King Faisal Specialist Hospital and Research Center (KFSH and RC), Riyadh, Saudi Arabia.
Mohamed
M
Alsebayel
Department of Medicine, Gastroenterology and Hepatology Unit (59), King Saud University, Riyadh, Saudi Arabia.
Waleed
W
Al Hamoudi
College of Medicine, Alfaisal University, Riyadh, Saudi Arabia ; Department of Liver and Small Bowel Transplantation and Hepatobiliary and Pancreatic Surgery, King Faisal Specialist Hospital and Research Center (KFSH and RC), Riyadh, Saudi Arabia.
Hussien
H
Elsiesy
Cryptococcal; Hyponatremia; Liver Transplantation; Meningitis; Syndrome of Inappropriate ADH (SIADH) Secretion