A 41-year-old Caucasian man presented to the emergency department with a 1-month history of jaundice, hallucinations, and ataxia. He was initially treated for acute alcoholic hepatitis with pentoxifylline and steroids, hepatic encephalopathy with lactulose, and started on empiric therapy for spontaneous bacterial peritonitis (SBP) with ceftriaxone. His mental status returned to baseline, but he continued to have worsening liver and renal failure. Hepatorenal syndrome was diagnosed and he was started on octreotide, midrodine and albumin. His medical history was notable for an ischemic stroke with mild residual deficit, gastric bypass surgery, uncomplicated lumbar spinal fusion surgery, and alcohol induced cirrhosis of the liver. Social history suggested that he consumed approximately one pint of vodka per day. Family history was noncontributory. He was not taking any medications at home. On hospital day 22, he sustained a tonic-clonic seizure, which lasted 4 minutes. Given his prolonged post-ictal state and low blood pressure he was transferred to the intensive care unit (ICU). Evaluation at that time revealed a severely obtunded and jaundiced man. Vital signs showed a temperature of 38.4°C, heart rate of 92 beats/min, blood pressure of 109/62, and respiratory rate of 19 breaths/min. Oxygen saturation by pulse oximetry was 95% on room air. Head and neck examination revealed scleral icterus and a supple neck. Diffuse coarse crackles were noted on auscultation of the chest. The cardiac rhythm was regular with a normal rate. No murmurs were appreciated. His abdomen was markedly distended, consistent with ascites. Guarding, rebound tenderness, and organomegaly were not appreciated. Neurologic examination revealed sluggish pupils, a weak gag reflex, and movement of the extremities only in response to painful stimuli. No asymmetry was appreciated. Laboratory studies were obtained and revealed a white blood cell (WBC) count of 62 × 103 cells/mm3, with 89% polymorphonucleated cells (PMNs), and a platelet count of 112 × 103 per mm3. His INR was 1.5. An extended metabolic and liver panel demonstrated: sodium 127 mEq/L, BUN 63 mg/dL, creatinine 6.8 mg/dL, total bilirubin 39.8 mg/dL, AST 201 U/L, ALT 109 U/L, and alkaline phosphatase 349 U/L. Ammonia was 38 μmol/L. Arterial blood gas showed a pH of 7.33, PCO2 of 35 mm Hg, PO2 of 184 mm Hg, and HCO3 concentration of 15 mEq/L on 40% oxygen. HIV antibody was found to be negative and HIV-1 RNA undetectable. Given his seizure, fever, and leukemoid reaction, he was started on empiric therapy with cefepime, vancomycin, ampicillin, and acyclovir. Levetiracetam (Keppra) was initiated for seizure control. An MRI of the brain was negative for any evidence of intracranial bleeding or other space occupying lesions. An EEG was unremarkable. Lumbar puncture was attempted, but unsuccessful due to the patient's prior spine surgery. Paracentesis revealed ascitic fluid with a WBC of 797 per mm3 with 81% PMNs, despite therapy with ceftriaxone. Ascites gram stain, bacterial and fungal cultures were negative. Because of his progressive clinical deterioration amphotericin was added to his regimen on hospital day 23. Lumbar puncture under fluoroscopy was performed on hospital day 24 and cerebrospinal fluid (CSF) analysis revealed 104 WBCs per mm3 with 98% PMNS, glucose 47 mg/dL, and protein 84 mg/dL. CSF gram stain demonstrated yeast and culture grew Cryptococcus neoforman. CSF cryptococcal antigen was also positive. Though initially negative, blood cultures also grew C. neoformans. Flucytosine was added to his medical regimen for better CSF coverage. The patient was diagnosed with disseminated cryptococcosis with meningitis, peritonitis, and cryptococcemia. Meningitis and cryptococcemia, as demonstrated by positive Cryptococcus neoformans cultures, and peritonitis, based on peritoneal fluid leukocytosis in the setting of low suspicion for SBP. The leukemoid reaction was attributed to alcoholic hepatitis, as cryptococcemia is not a known cause and no other infections were identified. Unfortunately, the patient continued to deteriorate with refractory hypotension and multi-system organ failure. Given his overall clinical picture and poor prognosis, the patient's family ultimately elected to withdraw life supporting measures. The patient expired soon thereafter.