P6047 - A Unique Case of Probiotic Fungemia in a Cirrhosis Patient

Ussama Ghumman, MD¹, Krystal Cruz Escobar, DO¹, Lisa D. Pedicone, PhD², Andres Gomez-Aldana, MD², Jan Petrasek, MD¹, Carmen landaverde, MD¹, Eric Lawitz, MD³, Fred Poordad, MD¹, Fabian Rodas, MD¹, Eugenia Tsai, MD³
1University of Texas Health San Antonio, San Antonio, TX; 2Texas Liver Institute, Austin, TX; 3Texas Liver Institute, San Antonio, TX

Introduction: Immune dysfunction in cirrhosis predisposes patients to serious infections. While bacterial infections are well documented, data on fungal infections and their management is limited. We present a unique case of probiotic fungemia in a patient with cirrhosis.

Case Description/

Methods: A 61-year-old male with alcohol-associated cirrhosis decompensated by ascites requiring frequent large volume paracentesis, hepatic encephalopathy (HE) and chronic kidney disease was admitted for altered mental status. On presentation labs included AST 32 U/L, ALT 16 U/L, total bilirubin 2.1 mg/dL, alkaline phosphatase 64 U/L, INR 1.3 and MELD 3.0 of 30. A full infectious workup including a diagnostic paracentesis was initially negative for infection. The patient’s mentation improved with optimization of lactulose and rifaximin however hospitalization was prolonged by renal failure and recurrent grade 3 HE leading to aspiration requiring intubation. Patient subsequently had hypotension refractory to resuscitation with a BP of 75/50 requiring norepinephrine 0.22 mcg/kg/min and vasopressin 0.04 U/min with lactic acid of 11.1 mmol/L. Repeat infectious workup including respiratory cultures grew extended-spectrum beta-lactamases Enterobacter cloacae for which meropenem was initiated and blood cultures grew budding yeast and intravenous micafungin was started. Further speciation identified Saccharomyces cerevisiae (S. cerevisiae) and amphotericin B and flucytosine were initiated. Additional history obtained from the family revealed patient was drinking expired probiotic shakes at home. Patient completed a two-week course with clinical improvement.

Discussion: Immune dysfunction in cirrhosis increases the risk of fungemia due to malnutrition altering metabolism, impaired synthetic function, decreased immune surveillance, and systemic inflammation. S. cerevisiae, found in probiotic supplements, is emerging in immunocompromised patients and is linked to worse outcomes than infection with the more common S. boulardii. Though marketed for gut health, these products pose significant risks to immunocompromised patients. Diagnosis can be difficult as Saccharomyces invasive infections present almost identically to invasive candidiasis. Key diagnostic tools include fungal markers, cultures, BAL, and biopsy. As demonstrated in this case, thorough history taking, awareness of sub-population susceptibility and early diagnosis are critical, as fungal infections can increase mortality.

Disclosures:
Ussama Ghumman indicated no relevant financial relationships.
Krystal Cruz Escobar indicated no relevant financial relationships.
Lisa D. Pedicone indicated no relevant financial relationships.
Andres Gomez-Aldana indicated no relevant financial relationships.
Jan Petrasek indicated no relevant financial relationships.
Carmen landaverde indicated no relevant financial relationships.
Eric Lawitz: 89 Bio INC – Consultant, Grant/Research Support, Speakers Bureau. Abbvie – Speakers Bureau. Akero Therapeitics – Grant/Research Support. Alnylam Phamaceuticals INC – Grant/Research Support. Amgen – Grant/Research Support. Aztrazeneca – Consultant, Grant/Research Support. Bioscience – Grant/Research Support. Boehringer Ingelheim – Consultant, Grant/Research Support. Bristol-Myers Squibb – Grant/Research Support. Corcept Therapeutics – Consultant, Grant/Research Support. Cour Pharmaceuticals Inc – Grant/Research Support. Cymabay Therapeutics – Grant/Research Support. Eli Lily and Company – Consultant, Grant/Research Support. Enanta Pharmaceuticals – Grant/Research Support. Enyo Pharma – Grant/Research Support. Exalenz – Grant/Research Support. Galectin Therapeutics – Grant/Research Support. Galmed Pharmaceuticals – Grant/Research Support. Genfit – Grant/Research Support. Gilead Sciences – Grant/Research Support, Speakers Bureau. GlaxoSmithKline – Grant/Research Support. Hanmi Pharmaceuticals – Grant/Research Support. Hightide Biopharma – Grant/Research Support. Intercept Pharmaceuticals – Grant/Research Support, Speakers Bureau. Inventiva – Grant/Research Support. Ipsen – Grant/Research Support. Jansen Pharmaceuticals – Grant/Research Support. Madrigal Pharmaceuticals – Grant/Research Support, Speakers Bureau. Merck & Co – Consultant, Grant/Research Support. NGM Biopharmaceuticals Inc – Grant/Research Support. Northsea Therapeutics – Grant/Research Support. Novartis – Grant/Research Support. Novo Nordisk Inc – Consultant, Grant/Research Support. Organovo – Consultant, Grant/Research Support. Poxel Co – Grant/Research Support. Regeneron – Consultant, Grant/Research Support. Sagimet Biosciences – Consultant, Grant/Research Support. Takeda – Grant/Research Support. Terns pharmaceuticals – Grant/Research Support. Viking Therapeutics – Grant/Research Support. Zydus Pharmaceuticals – Grant/Research Support.
Fred Poordad indicated no relevant financial relationships.
Fabian Rodas indicated no relevant financial relationships.
Eugenia Tsai indicated no relevant financial relationships.

Ussama Ghumman, MD¹, Krystal Cruz Escobar, DO¹, Lisa D. Pedicone, PhD², Andres Gomez-Aldana, MD², Jan Petrasek, MD¹, Carmen landaverde, MD¹, Eric Lawitz, MD³, Fred Poordad, MD¹, Fabian Rodas, MD¹, Eugenia Tsai, MD³. P6047 - A Unique Case of Probiotic Fungemia in a Cirrhosis Patient, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.