Dermatologic complications after liver transplantation: a single-center experience

Evidence in the prevention of the recurrence of herpes simplex and herpes zoster keratitis after eye surgery

OBJECTIVE

Herpetic keratitis, either due to herpes simplex keratitis (HSK) or herpes zoster ophthalmicus (HZO), can recur after eye surgery.º Prophylaxis is postulated as necessary to avoid it. The objective of this study was to review the scientific evidence on the preventive methods used in the perioperative period in patients previously affected by HSK/HZO.

METHODS

An exhaustive search was carried out in the PubMed and Web of Science databases to identify relevant articles on prophylaxis and risk of recurrence of HSK/HZO in patients undergoing eye surgery up to 31 December 2019.

RESULTS

There is strong evidence that oral prophylaxis should be recommended after penetrating keratoplasty in patients who have previously had HSK/HZO. For other types of surgery, the evidence is less compelling. However, a latent period of inactivity should be considered between disease and oral prophylaxis.

CONCLUSIONS

Penetrating and lamellar keratoplasty, corneal crosslinking, cataract surgery, and photorefractive and phototherapeutic surgery cause an alteration of the subbasal nerve plexus of the cornea. Due to surgical trauma, as well as the modulation of the ocular immune response caused by steroids applied in the postoperative period, it is possible to induce the reactivation of HSK/HZO, which is common in some cases. Within this article, we discuss the available evidence for HSK/HZO prophylaxis in eye surgery. Further studies are necessary to define the real risk of HSK/HZO recurrence after ocular surgeries, particularly in cataract surgery, and to confirm the efficacy of perioperative prophylaxis with anti-HSK/HZO antivirals.

Dermatological signs in liver transplant recipients

BACKGROUND

In recent years, the number of liver transplantations for advanced-stage liver diseases has considerably increased and the patients have a wide range of dermatologic manifestations.

AIM

This study aims to reveal cutaneous, mucosal, and nail lesions in liver transplant recipients in quite large patient series.

PATIENTS/METHODS

The study included 520 patients in the Inonu University Liver Transplantation Institute. New and followed-up patients attended to the study between May and October 2019. The patients were examined by a dermatologist, and their data were recorded.

RESULTS

The study included 163 female and 357 male patients with the main age of 44.20 ± 18.18 (range: 1-83 years), and 465 livers (89.4%) were taken from live donors, while 54 livers (10.4%) were taken from cadavers. A total of 314 (60.4%) patients had dermatophyte infections, 174 (33.4%) patients had pathological nail changes, and 427 (82.1%) patients had oral mucosal lesions. Graft-versus-host disease (GVHD) developed in 9 (1.73%) patients after the transplantation, and 5 patients died of GVHD. Four patients had cutaneous malignancies.

CONCLUSIONS

Tumoral and nontumoral dermatological diseases may be encountered following the transplantation depending on underlying liver disease, immunosuppressive treatment, the graft itself, or any primary cutaneous disease. Liver transplantation recipients require a multidisciplinary clinical approach, and dermatological care must be an integral part of this approach.

Ocular surgery after herpes simplex and herpes zoster keratitis

PURPOSE

The recurrence of herpetic stromal keratitis (HSK) and herpes zoster ophthalmicus (HZO) has been reported after a variety of ocular surgeries. The aim of this study was to review the evidence on the preventive methods employed in the perioperative period in patients having undergone HSK/HZO.

METHODS

The PubMed and Web of Science databases were the main resources used to conduct the medical literature search. An extensive search was performed to identify relevant articles concerning the prophylaxis against and risk of HSK/HZO recurrence in patients undergoing ocular surgery up to December 31, 2019.

RESULTS

The disturbance of the corneal nerve plexus occurs during several ocular surgeries including penetrating keratoplasty, lamellar keratoplasty, corneal cross-linking, cataract surgery, as well as photorefractive and phototherapeutic procedures. Such trauma, as well as modulation of the ocular immunological response caused by steroids applied postoperatively, might engender the HSK/HZO reactivation which is not uncommon. There is strong evidence that oral prophylaxis should be recommended just after surgery in patients undergoing penetrating keratoplasty and having suffered from HSK/HZO. For other types of surgeries, the evidence is less compelling; nevertheless, a period of disease quiescence and oral prophylaxis should still be considered.

CONCLUSIONS

Within the article, we discuss the available evidence for HSK/HZO prophylaxis in ocular surgery. Additional studies would be required to define the real risk of HSK/HZO recurrence following eye surgeries, and particularly cataract surgery, and to confirm the utility of perioperative HSK/HZO prophylaxis.

Dermatological Disorders following Liver Transplantation: An Update

Patients undergoing liver transplantation (LT) are at a high risk of dermatological complications compared to the general population as a result of long-term use of immunosuppressant. However, the risk is not as high as other solid organ transplantations (SOT), particularly for skin cancer. The liver is considered as an immune privileged organ since it has a low prevalence of humoral rejection in contrast to other SOT, and thus, LT requires a minimal amount of immunosuppressants compared to other SOT recipients. However, because of the large volume of the liver, patients with LT have higher donor lymphocytes that sometimes may trigger graft-versus-host-disease, yet it is rare. On the other hand, the vast majority of the nonspecific dermatological lesions linked with cirrhosis improve after removal of diseased liver or due to the immunosuppressant used after LT. Nevertheless, dermatological infections related to bacteria, viruses, and fungus after LT are not uncommon. Additionally, the incidence of IgE-mediated food allergies develops in 12.2% of LT patients and may present as life-threatening conditions such as urticaria and/or angioedema and hypersensitivity. Moreover, skin malignancies after LT are a matter of concern. Thus, posttransplant dermatological care should be provided to all LT patients for any suspicious dermatological lesions. Our goal is to give an outline of the dermatological manifestation associated with LT for the clinicians by collecting the published data from all archived case reports.

Improved survival after LTx-associated acute GVHD with mAb therapy targeting IL2RAb and soluble TNFAb: Single-center experience and systematic review

Acute graft-versus-host disease (GVHD) after liver transplant (LTx) is a rare complication with a high mortality rate. Recently, monoclonal antibody (mAb) treatment, specifically with anti-interleukin 2 receptor antibodies (IL2RAb) and anti-tumor necrosis factor-α antibodies (TNFAb), has gained increasing interest. However, evidence is mostly limited to case reports and the efficacy remains unclear. Here, we describe 5 patients with LTx-associated GVHD from our center and provide the results of our systematic literature review to evaluate the potential therapeutic benefit of IL2RAb/TNFAb treatment. Of the combined population of 155 patients (5 in our center and 150 through systematic search), 24 were given mAb (15.5%)-4 with TNFAb (2.6%) and 17 with IL2RAb (11%) ("mAb group")-and compared with patients who received other treatments (referred to as "no-mAb group"). Two-sided Fisher exact tests revealed a better survival when comparing treatment with mAb versus no-mAb (11/24 vs 27/131; P = .018), TNFAb versus no-mAb (3/4 vs 27/131; P = .034), and IL2RAb versus no-mAb (8/17 vs 27/131; P = .029). This systematic review suggests a beneficial effect of mAb treatment and a promising role for TNFAb and IL2RAb as a first-line strategy to treat LTx-associated acute GVHD.

Graft Versus Host Disease After Liver Transplantation in Adults: A Case series, Review of Literature, and an Approach to Management

BACKGROUND

Graft-versus-host-disease (GVHD) after liver transplantation (LT) is a deadly complication with very limited data on risk factors, diagnosis and management. We report a case series and a comprehensive review of the literature.

METHODS

Data were systematically extracted from reports of GVHD after LT, and from the United Network for Organ Sharing database. Group comparisons were performed.

RESULTS

One hundred fifty-six adult patients with GVHD after LT have been reported. Median time to GVHD onset was 28 days. Clinical features were skin rash (92%), pancytopenia (78%), and diarrhea (65%). Six-month mortality with GVHD after LT was 73%. Sepsis was the most common cause of death (60%). Enterobacter bacteremia, invasive aspergillosis, and disseminated Candida infections were frequently reported. Recipient age over 50 years is a risk factor for GVHD after LT. Hepatocellular carcinoma was overrepresented, whereas chronic hepatitis C was underrepresented, in reported United States GVHD cases relative to all United Network for Organ Sharing database LT cases. Mortality rate with treatment of GVHD after LT was 84% with high-dose steroids alone, 75% to 100% with regimens using dose increases of calcineurin inhibitors, and 55% with IL-2 antagonists. Mortality was 25% in small case series using the CD2-blocker alefacept or TNF-α antagonists.

CONCLUSIONS

Age older than 50 years and hepatocellular carcinoma appear to be risk factors for GVHD. Hepatitis C may be protective. High-dose steroids and calcineurin inhibitors are ineffective in the treatment of GVHD after LT. CD2-blockers and TNF-α antagonists appear promising. We propose a diagnostic algorithm to assist clinicians in managing adults with GVHD after LT.

Hormonal profile and androgen receptor study in prepubertal girls with hypertrichosis

Background

Prepubertal hypertrichosis is a reportedly benign condition characterized by an excessive growth of vellous hair in non-androgen dependent areas of the body compared to the amount usually present in normal subjects of the same age, race and sex. Although this condition is usually considered idiopathic and regarded as benign, it may be very disturbing cosmetically, causing significant patient and parental anxiety.

Method

We performed a hormonal and androgen receptor study in 42 prepubertal girls with hypertrichosis and 29 control girls from 2 to 8 years of age. Both groups underwent a determination of basal LH, FSH, 17OH progesterone, androstenedione, testosterone, estradiol and SHBG, abdominal ultrasound to assess ovarian morphology, and the number of androgen receptor CAG/GGC repeats in DNA obtained from peripheral leukocytes.

Results

The hypertrichosis score was higher in the cases compared to controls. Serum gonadotropins and sex steroids were similar in both groups, but SHBG was significantly lower in the girls with hypertrichosis (71.1 ± 2.9 vs 81.9 ± 3.0 nmol/L, p < 0.02). The distribution of shorter, larger and total alleles was not statistically different between cases and controls. The combined analysis of CAG/GGC, however, showed a significantly higher prevalence of the most androgen-sensitive haplotypes (1–2: <22CAG + 17/17GGC- < 14CAG + 17/18GGC) in girls with hypertrichosis compared to controls.

Conclusions

We conclude that girls with hypertrychosis exhibit AR(s) with enhanced sensitivity, which may facilitate the growth of their body hair.

Graft-versus-host disease after liver transplantation: A comprehensive literature review

AIM: To determine the factors affecting mortality in patients who developed graft-versus-host disease (GvHD) after liver transplantation (LT).

METHODS: We performed a review of studies of GvHD following LT published in the English literature and accessed the PubMed, Medline, EBSCO, EMBASE, and Google Scholar databases. Using relevant search phrases, 88 articles were identified. Of these, 61 articles containing most of the study parameters were considered eligible for the study. Risk factors were first examined using a univariate Kaplan-Meier model, and variables with a significant association (P < 0.05) were then subjected to multivariate analyses using a Cox proportional-hazards model.

RESULTS: The 61 articles reported 87 patients, 58 male and 29 female, mean age, 40.4 ± 15.5 years (range: 8 mo to 74 years), who met the inclusion criteria for the present study. Deaths occurred in 59 (67.8%) patients, whereas 28 (32.2%) survived after a mean follow-up period of 280.8 ± 316.2 d (range: 27-2285 d). Among the most frequent symptoms were rash (94.2%), fever (66.6%), diarrhea (54%), and pancytopenia (54%). The average time period between LT and first symptom onset was 60.6 ± 190.1 d (range: 2-1865 d). The Kaplan-Meier analysis revealed that pancytopenia (42.8% vs 59.3%, P = 0.03), diarrhea (39.2% vs 61.0%, P = 0.04), age difference between the recipient and the donor (14.6 ± 3.1 years vs 22.6 ± 2.7 years, P < 0.0001), and time from first symptom occurrence to diagnosis or treatment (13.3 ± 2.6 mo vs 15.0 ± 2.3 mo, P < 0.0001) were significant factors affecting mortality, whereas age, sex, presence of rash and fever, use of immunosuppressive agents, acute rejection before GvHD, etiological causes, time of onset, and donor type were not associated with mortality risk. The Cox proportional-hazards model, determined that an age difference between the recipient and donor was an independent risk factor (P = 0.03; hazard ratio, 7.395, 95% confidence interval, 1.2-46.7).

CONCLUSION: This study showed that an age difference between the recipient and donor is an independent risk factor for mortality in patients who develop GvHD after LT.

Kaposi sarcoma in the setting of cushing disease

OBJECTIVE

To report a case of a human immunodeficiency virus (HIV)-negative Kaposi sarcoma (KS) associated with Cushing disease (CD).

METHODS

The details of case presentation, evaluation, diagnosis, and treatment are presented and cases of KS and CD published before November 1, 2010 on PubMed and Scopus are reviewed.

RESULTS

A 54-year-old Hispanic HIV-negative man presented with typical signs and symptoms of CD (easy bruisability, proximal muscle wasting, and abdominal fat pads). Numerous raised, purplish, nonblanching plaques 0.5 to 2 cm in diameter extended throughout his lower extremities. Biochemical tests and pituitary magnetic resonance imaging confirmed CD. A lesion biopsy showed atypical vascular proliferation positive by immunohistochemistry for human herpesvirus 8 (HHV-8), consistent with KS. He underwent 2 transsphenoidal surgeries followed by a bilateral adrenalectomy. After recovery, his KS was treated with a systemic combination of liposomal doxorubicin and paclitaxel.

CONCLUSION

The occurrence of CD and KS is rare. Specific therapy for CD and chemotherapy for KS are effective in the treatment of KS associated with CD.

New concepts in the prevention of pressure sores

Pressure sores are a serious, and costly, complication for many patients with reduced mobility and sensation. Some populations, such as those with spinal cord injury (SCI), remain at high risk throughout their lifetime. Prevention is highly preferable and while the concept is readily definable, it is much more challenging to develop valid preventative measures. Subjective and objective approaches to risk factor assessment before pressure sores develop are reviewed, including risk status scales and emerging techniques to assess deep tissue injury. Devices to prevent pressure sores have traditionally focused on pressure-relieving cushions and mattresses. Technological advances being applied in the development of new pressure sore prevention devices are presented. Clinical evidence-based practice is integral to pressure sore prevention. Comprehensive assessment must include evaluation of systemic diseases, anatomical and physiological factors, together with environmental and psychosocial factors, which can all contribute to pressure sore development. Extrinsic factors need to be considered in conjunction with intrinsic tissue health factors and are reviewed together with an evaluation of currently available clinical practice guidelines. This chapter presents the broad diversity of factors associated with pressure sore development and highlights the need for an interdisciplinary team approach in order to maximize successful prevention of pressure sores.

New-onset herpes simplex virus keratitis after cataract surgery

We report the case of a 34-year-old man who had uncomplicated cataract surgery in his left eye. Medical history was significant for atopic dermatitis, requiring oral immunosuppressive medications. Two days after the surgery, the patient presented with pain, photophobia, decreased vision, and a small corneal abrasion. On postoperative day 5, the patient returned with left upper lid vesicular lesions and 2 corneal dendrites. Corrected vision was 20/100 OS, with intraocular pressure of 18 mm Hg and 1+ pigmented cells in the anterior chamber. Cultures of the lid lesions revealed herpes simplex virus (HSV) type 1. The patient was placed on oral acyclovir 800 mg 5 times a day. By day 8, the dendrites had resolved, and by day 15, the lid lesions healed over. HSV keratitis is an uncommon complication after cataract surgery. Ophthalmologists should be aware of the possibility of developing HSV keratitis even after the most routine cataract extraction.