Things can get pretty weird in cirrhosis, not all the usual patterns that we're used to seeing are there.

For instance, if a serotic is infected, it's kind of useless to check a C-reactive protein or a pro-calcitonin.

Because C-reactive protein and pro-calcitonin are elevated in cirrhosis even if you don't have an infection.

Another major issue is that when you see something like decompensated cirrhosis, a lot of these patients have

impaired immune response so they don't mount for instance fevers in response to infections.

So a lot of the time we see things like altered mental status and we think it's just

hepatic encephalopathy because they're not taking nor lactulose or they need lactulose but maybe

it's an infection that's causing that altermental status.

Or we see acute kidney injury and we attribute it to hepatorenal syndrome without infection.

The cruelty of experience is that you gain it just after you need it, and there are so many

times and there will be so many times in the future where I will learn things with patients from cirrhosis

too late. Meaning a lot of times with serotics, I don't know what I don't know. Like I can be giving

antibiotics and it seems like the patient's infected but they're just not getting better. So you have

to think and think and think.

Now, that's not always easy. My wife spends more time wondering what I am thinking than I actually

spend time thinking, but in these patients, sometimes I just have to take myself aside and really

ponder what might be going on. So for example, some infected serotic patients, they're not responding to

antibiotics. Very often they have negative bacterial cultures. Even if they do have a bacterial infection,

they might have a negative bacterial culture. But let's say they're not responding to antibiotics

and they seem infected. Well, about 10% of infections, maybe a little bit more,

are fungal infections. And a lot of the time, well, I shouldn't say a lot of time, but it happens

that sometimes you have both a dual bacterial and fungal infection, which definitely

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