A 56-Year-Old Woman with End-Stage Liver Disease and Headache

This case profiles a 56-year-old woman with end-stage liver disease secondary to metabolic dysfunction-associated steatohepatitis, who presented with subacute confusion, abdominal pain, and a worsening headache. Initial symptoms aligned with hepatic encephalopathy, which improved with lactulose and rifaximin. Imaging showed cirrhotic liver morphology, ascites, and mild white matter changes. Her headache evolved atypically, with photophobia and unilateral blurred vision. MRI revealed basal ganglia lesions and diffuse sulcal hyperintensity. A serum cryptococcal antigen was positive, and CSF analysis confirmed cryptococcal meningoencephalitis due to Cryptococcus neoformans, with elevated intracranial pressure. Management included serial lumbar punctures, liposomal amphotericin B induction, and fluconazole consolidation. Despite transient improvement, she was readmitted weeks later with multiorgan failure and died following transition to comfort measures. The case underscores diagnostic nuance in secondary headache and highlights high mortality risk of cryptococcal disease in cirrhosis-associated immunosuppression.

This case profiles a 56-year-old woman with end-stage liver disease secondary to metabolic dysfunction-associated steatohepatitis, who presented with subacute confusion, abdominal pain, and a worsening headache. Initial symptoms aligned with hepatic encephalopathy, which improved with lactulose and rifaximin. Imaging showed cirrhotic liver morphology, ascites, and mild white matter changes. Her headache evolved atypically, with photophobia and unilateral blurred vision. MRI revealed basal ganglia lesions and diffuse sulcal hyperintensity. A serum cryptococcal antigen was positive, and CSF analysis confirmed cryptococcal meningoencephalitis due to Cryptococcus neoformans, with elevated intracranial pressure. Management included serial lumbar punctures, liposomal amphotericin B induction, and fluconazole consolidation. Despite transient improvement, she was readmitted weeks later with multiorgan failure and died following transition to comfort measures. The case underscores diagnostic nuance in secondary headache and highlights high mortality risk of cryptococcal disease in cirrhosis-associated immunosuppression.