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Long term outcome of medical and surgical co-management of craniospinal aspergillosis in an immunocompromised patient. Med Mycol Case Rep 2016; 14:33-37. [PMID: 28053849 PMCID: PMC5198800 DOI: 10.1016/j.mmcr.2016.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/25/2016] [Accepted: 11/28/2016] [Indexed: 11/20/2022] Open
Abstract
35 yr old steroid dependent lady with Pulmonary TB underwent debridement of epidural abscess & posterior stabilization for paraparesis. With histopathology and cultures showing Aspergillus fumigatus, voricanozole was started. By the fourth week, she developed persistent fever, and altered mental status. Brain MRI and CSF study including multiplex PCR evaluation confirmed cerebral aspergillosis. Voricanozole was changed to intravenous lipid complex Amphotericin B to achieve sustained clinical and radiological response after six months of therapy.
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2
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Hicheri Y, Cook G, Cordonnier C. Antifungal prophylaxis in haematology patients: the role of voriconazole. Clin Microbiol Infect 2012; 18 Suppl 2:1-15. [DOI: 10.1111/j.1469-0691.2012.03772.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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3
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Walsh TJ, Anaissie EJ, Denning DW, Herbrecht R, Kontoyiannis DP, Marr KA, Morrison VA, Segal BH, Steinbach WJ, Stevens DA, van Burik JA, Wingard JR, Patterson TF. Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis 2008; 46:327-60. [PMID: 18177225 DOI: 10.1086/525258] [Citation(s) in RCA: 1834] [Impact Index Per Article: 114.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Thomas J Walsh
- Pediatric Oncology Branch, National Cancer Institute, Bethesda, Maryland, USA
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4
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Walsh T, Anaissie E, Denning D, Herbrecht R, Kontoyiannis D, Marr K, Morrison V, Segal B, Steinbach W, Stevens D, van Burik J, Wingard J, Patterson Y. Tratamiento de la Aspergilosis: Guías para la práctica clínica de la Sociedad de Enfermedades Infecciosas de los Estados Unidos de América (IDSA). Clin Infect Dis 2008. [DOI: 10.1086/590225] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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5
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Sipsas NV, Kontoyiannis DP. Clinical Issues Regarding Relapsing Aspergillosis and the Efficacy of Secondary Antifungal Prophylaxis in Patients with Hematological Malignancies. Clin Infect Dis 2006; 42:1584-91. [PMID: 16652316 DOI: 10.1086/503844] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2005] [Accepted: 02/22/2006] [Indexed: 11/04/2022] Open
Abstract
Advancements in early diagnosis and the introduction of effective agents have improved the rates of response of aspergillosis to primary antifungal therapy. These changes allow the subsequent continuation of cytotoxic chemotherapy and/or performance of hematopoietic stem cell transplantation in an increasing number of patients with hematological malignancies. These developments have increased interest in secondary prophylaxis of aspergillosis, because the resumption of myelotoxic chemotherapy in these patients is associated with high rates of relapse of this opportunistic mycosis in the absence of prophylaxis. However, the risk factors for relapsing invasive aspergillosis and the strategies for reducing risk are not well defined. Furthermore, differentiating aspergillosis relapse from reinfection with a new Aspergillus isolate is problematic when using the available laboratory tools. We summarize the existing knowledge regarding the pathogenesis of, risk factors for, and natural history of relapsing invasive aspergillosis and review the limited data regarding the role of secondary antifungal prophylaxis.
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Affiliation(s)
- Nikolaos V Sipsas
- Infectious Diseases Unit, Pathophysiology Department, Laikon General Hospital, Athens, Greece
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6
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Cordonnier C, Maury S, Pautas C, Bastié JN, Chehata S, Castaigne S, Kuentz M, Bretagne S, Ribaud P. Secondary antifungal prophylaxis with voriconazole to adhere to scheduled treatment in leukemic patients and stem cell transplant recipients. Bone Marrow Transplant 2004; 33:943-8. [PMID: 15034546 DOI: 10.1038/sj.bmt.1704469] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Although the efficacy and safety of voriconazole to treat invasive fungal infections have been demonstrated in prospective trials, its use for secondary prophylaxis to prevent reactivation of these infections remains unknown. Delaying the scheduled treatment of leukemia until complete resolution of fungal infection may have major implications for prognosis. We report 11 leukemic patients with previous aspergillus (n=10) and candida (n=1) infection who received voriconazole 400 mg/day intravenously or orally for between 44 and 245 days. Nine patients were scheduled for allogeneic stem cell transplant, and two for consolidation therapy for acute leukemia. None of the patients had a relapse of fungal infection, and scheduled treatment was delayed only once. Voriconazole was well tolerated, except in one patient who had abnormal liver tests secondary to hepatic graft-versus-host disease, and one who had visual disturbances. This small but homogeneous series indicates that voriconazole may be useful to prevent fungal relapse during at-risk periods in leukemic patients. Prospective trials are warranted to confirm these encouraging results.
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Affiliation(s)
- C Cordonnier
- Hematology Department, Henri Mondor Hospital, Créteil, France.
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7
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Castagnola E, Machetti M, Bucci B, Viscoli C. Antifungal prophylaxis with azole derivatives. Clin Microbiol Infect 2004; 10 Suppl 1:86-95. [PMID: 14748805 DOI: 10.1111/j.1470-9465.2004.00847.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In recent years, several reports have underlined the increasing role of fungal infections as a cause of morbidity and mortality in hospitalised patients. For this reason, and also in light of the high mortality rate associated with these infections, chemoprophylaxis has been advocated by several authors. The available evidence suggests that both fluconazole and itraconazole are able to decrease candida colonisation and infection, when compared with placebo or with nonabsorbable antifungals. Data seem also to suggest that a decrease in fungus-related mortality can be achieved with prophylaxis, although with little effect on overall mortality, probably because of the importance of severe underlying diseases. Itraconazole proved to be effective in the prevention of fungal infections, including invasive aspergillosis, although with increased incidence of side-effects, often leading to treatment discontinuation. The other side of the coin is that antifungal prophylaxis might have untoward effects, such as the selection of triazole-resistant Candida strains or the induction of resistance. In addition, some authors have suggested that the use of triazoles might modulate the pattern of infecting organisms in cancer patients, increasing the risk of both aspergillosis and bacteremia. In conclusion, antifungal prophylaxis with triazole antifungals should be used with caution, only in patients at high risk for invasive fungal infections. These include allogeneic bone marrow transplant patients (especially those with mismatched or unrelated donors), acute myeloid leukaemia patients treated with high-dose cytarabine (C-ara), very-low-birth-weight infants, patients with chronic granulomatous disease, and high-risk surgical and intensive-care unit patients.
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Affiliation(s)
- E Castagnola
- Infectious Diseases Unit and Department of Haematology and Oncology, G.Gaslini Children's Hospital, Genoa, Italy
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8
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McCracken D, Barnes R, Poynton C, White PL, Işik N, Cook D. Polymerase chain reaction aids in the diagnosis of an unusual case of Aspergillus niger endocarditis in a patient with acute myeloid leukaemia. J Infect 2003; 47:344-7. [PMID: 14556761 DOI: 10.1016/s0163-4453(03)00084-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Endocarditis secondary to Aspergillus niger has not been described in a leukaemic patient. We describe a case of A. niger endocarditis in a patient with acute myeloid leukaemia and refractory fever. The microbiological cause of his endocarditis was initially misdiagnosed because he fulfilled the Duke criteria for enterococcal endocarditis. A polymerase chain reaction test utilizing pan-fungal primers detected a product from an Aspergillus sp. The DNA was subsequently sequenced and was found to have 100% homology with A. niger. A postmortem revealed fungal endocarditis secondary to disseminated aspergillosis, without evidence of bacterial endocarditis. The patient was found to have a lung aspergilloma that was possibly occupationally acquired, and may have been long standing.
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Affiliation(s)
- D McCracken
- Department of Medical Microbiology and NPHS, University Hospital of Wales, Cardiff, UK.
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9
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Gow KW, Hayes-Jordan AA, Billups CA, Shenep JL, Hoffer FA, Davidoff AM, Rao BN, Schropp KP, Shochat SJ. Benefit of surgical resection of invasive pulmonary aspergillosis in pediatric patients undergoing treatment for malignancies and immunodeficiency syndromes. J Pediatr Surg 2003; 38:1354-60. [PMID: 14523819 DOI: 10.1016/s0022-3468(03)00395-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE The aim of this study was to evaluate the outcome of children undergoing treatment for malignancy and immunodeficiency syndromes in whom invasive pulmonary aspergillosis (IPA) developed. METHODS The authors reviewed the medical records of all patients treated at their institution from January 1990 to August 1999 for culture-proven pulmonary aspergillus infection. RESULTS Among the 43 patients studied, the median age at the time of diagnosis of IPA was 13.1 years. The most common primary diagnoses were acute myelogenous leukemia (n = 18) and acute lymphoblastic leukemia (n = 14); 27 patients (63%) had received a bone marrow transplant (BMT). Of the 18 patients who underwent surgical intervention for IPA, 14 (78%) had one operation, whereas the remaining 4 patients had 2. The 4 patients alive at the time this report was written had undergone surgical intervention 2, 10, 23, and 44 months previously respectively. Surgical resection of the involved lung parenchyma was significantly prognostic for survival (P <.001). Other factors that influenced outcome were the extent of pulmonary invasion, steroid use, and the timing of bone marrow transplantation (BMT) in regard to the diagnosis of IPA. CONCLUSIONS The overall mortality rate of children treated for malignancies and immunodeficiency syndromes in who IPA develops remains high, and antifungal therapy alone may not be curative. Surgical resection may provide a small but possibly the only chance for survival. Therefore, we would advocate for resection of all involved tissue, even if it requires reoperation.
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Affiliation(s)
- Kenneth W Gow
- Department of Surgery, St Jude Children's Research Hospital, Memphis, TN 38105-2794, USA
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10
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Mattei D, Mordini N, Lo Nigro C, Ghirardo D, Ferrua MT, Osenda M, Gallamini A, Bacigalupo A, Viscoli C. Voriconazole in the management of invasive aspergillosis in two patients with acute myeloid leukemia undergoing stem cell transplantation. Bone Marrow Transplant 2002; 30:967-70. [PMID: 12476292 DOI: 10.1038/sj.bmt.1703763] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2002] [Accepted: 08/10/2002] [Indexed: 11/09/2022]
Abstract
The management of invasive aspergillosis in patients with hematological malignancies remains controversial. A major problem is how to manage patients who had invasive aspergillosis during remission induction and consolidation therapy and then undergo SCT. Indeed in these patients the mortality rate related to invasive aspergillosis recurrence remains unacceptably high. We report two cases of patients who underwent remission induction for AML, developed invasive aspergillosis during antifungal prophylaxis with itraconazole, failed amphotericin B deoxycholate and liposomal amphotericin B treatment, were successfully treated with voriconazole and eventually underwent SCT with voriconazole prophylaxis without reactivation of invasive aspergillosis.
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MESH Headings
- Adult
- Amphotericin B/administration & dosage
- Amphotericin B/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Aspergillosis/drug therapy
- Aspergillosis/etiology
- Aspergillosis/prevention & control
- Bone Marrow Transplantation/adverse effects
- Combined Modality Therapy
- Cytarabine/administration & dosage
- Cytarabine/adverse effects
- Daunorubicin/administration & dosage
- Daunorubicin/adverse effects
- Deoxycholic Acid/administration & dosage
- Deoxycholic Acid/analogs & derivatives
- Deoxycholic Acid/therapeutic use
- Drug Combinations
- Drug Resistance, Fungal
- Etoposide/administration & dosage
- Etoposide/adverse effects
- Fatal Outcome
- Humans
- Immunocompromised Host
- Itraconazole/therapeutic use
- Leukemia, Megakaryoblastic, Acute/complications
- Leukemia, Megakaryoblastic, Acute/drug therapy
- Leukemia, Megakaryoblastic, Acute/therapy
- Leukemia, Myelomonocytic, Acute/complications
- Leukemia, Myelomonocytic, Acute/drug therapy
- Leukemia, Myelomonocytic, Acute/therapy
- Liposomes
- Lung Diseases, Fungal/drug therapy
- Male
- Middle Aged
- Peripheral Blood Stem Cell Transplantation/adverse effects
- Pyrimidines/therapeutic use
- Recurrence
- Remission Induction
- Salvage Therapy
- Transplantation Conditioning/adverse effects
- Transplantation, Autologous/adverse effects
- Transplantation, Homologous/adverse effects
- Triazoles/therapeutic use
- Voriconazole
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Affiliation(s)
- D Mattei
- Hematology Department, S Croce Hospital, Cuneo, Italy
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11
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Derelle J. [Pulmonary complications in immunosuppressed children]. Arch Pediatr 2000; 7 Suppl 1:77S-81S. [PMID: 10793954 DOI: 10.1016/s0929-693x(00)88825-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Pulmonary complications, which are dominated by opportunistic infections, can be first manifestations of inherited or acquired pediatric immune deficiencies. Prompt diagnosis is essential. The epidemiology and natural history of these complications have changed as a result of major advances in prevention, diagnosis and treatment.
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Affiliation(s)
- J Derelle
- Service de pédiatrie 1, Hôpital d'Enfants, Vandoeuvre-lès-Nancy, France
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12
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Groll AH, Kurz M, Schneider W, Witt V, Schmidt H, Schneider M, Schwabe D. Five-year-survey of invasive aspergillosis in a paediatric cancer centre. Epidemiology, management and long-term survival. Mycoses 1999; 42:431-42. [PMID: 10546484 DOI: 10.1046/j.1439-0507.1999.00496.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The epidemiology, management, and long-term survival of invasive aspergillosis was assessed in a prospective, 5-year observational study in 346 unselected paediatric cancer patients receiving dose-intensive chemotherapy for newly diagnosed or recurrent malignancies. Invasive aspergillosis occurred exclusively in the context of haematological malignancies, where it accounted for an incidence of 6.8% (n = 13 of 189). The lung was the primary site in 12 cases, and dissemination was present in three of those. Prior to diagnosis, the overwhelming majority of patients had been profoundly neutropenic for at least 14 days (n = 11 of 13) and were receiving systemic antifungal agents (n = 10 of 13). Clinical signs and symptoms were nonspecific but always included fever. All 11 patients who were diagnosed and treated during lifetime for a minimum of 10 days responded to either medical or combined medical and surgical treatment, and seven were cured (64%). Nevertheless, the overall long-term survival was merely 31% after a median follow-up of 5.68 years after diagnosis. Apart from refractory or recurrent cancer, the main obstacles to successful outcome were failure to diagnose IA during lifetime and bleeding complications in patients with established diagnosis. The frequency of invasive aspergillosis of greater than 15% in paediatric patients with acute myeloblastic leukaemia and recurrent leukaemias warrants the systematic investigation of preventive strategies in these highly vulnerable subgroups.
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Affiliation(s)
- A H Groll
- Department of Pediatrics, Johann Wolfgang Goethe-University Hospital, Frankfurt am Main, Germany
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13
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Kaiser L, Huguenin T, Lew PD, Chapuis B, Pittet D. Invasive aspergillosis. Clinical features of 35 proven cases at a single institution. Medicine (Baltimore) 1998; 77:188-94. [PMID: 9653430 DOI: 10.1097/00005792-199805000-00004] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Thirty-five patients with clinical features and histologically or microbiologically proven infection met predetermined stringent criteria for invasive aspergillosis over a 5-year period at our institution. Underlying conditions included hematologic malignancy, solid tumor, bone marrow and solid organ transplantation, and immunosuppressive therapy. The majority of patients (94%) presented with respiratory symptoms and abnormal pulmonary chest radiography; only 40% had neutropenia at time of infection. Invasive aspergillosis was suspected in only 21 cases (60%). Concomitant infections were present in 83% of patients. Half of patients had pathogenic or potentially pathogenic microorganisms other than Aspergillus spp. isolated from pulmonary specimens at time of aspergillosis. Aspergillus spp. were recovered from sputum in 75% of patients and from bronchoalveolar lavage in only 52%. Invasive aspergillosis is an unexpectedly unrecognized disease with poor outcome; overall mortality was 94% in our series. The lack of sensitivity of diagnostic procedures, together with the high frequency of concomitant infections, delays the time of diagnosis. Early diagnostic tests are needed, and presumptive antifungal therapy among high-risk patients is mandatory.
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Affiliation(s)
- L Kaiser
- Division of Infectious Diseases, University of Geneva Hospitals, Switzerland
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14
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Tabbara KF, al Jabarti AL. Hospital construction-associated outbreak of ocular aspergillosis after cataract surgery. Ophthalmology 1998; 105:522-6. [PMID: 9499785 DOI: 10.1016/s0161-6420(98)93037-8] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE This study aimed to report an outbreak of Aspergillus endophthalmitis after cataract extraction during hospital construction. DESIGN The study design is a case series of an outbreak of Aspergillus endophthalmitis. PARTICIPANTS Five patients in whom Aspergillus endophthalmitis developed during a period of hospital construction in Jeddah, Saudi Arabia, participated. Severe postoperative uveitis occurred in all five patients and failed to subside with topical steroid therapy. The patients were referred to the King Khaled Eye Specialist Hospital for treatment. The causative organism was identified as Aspergillus fumigatus in each case. INTERVENTION All five patients were subjected to aqueous or vitreous tap. Three patients had vitrectomy. Patients were given systemic, periocular, and intravitreous antifungal agents. MAIN OUTCOME The final outcome in each patient was evisceration or enucleation, despite an intensive course of antifungal therapy. RESULTS There were five patients, three females and two males, ranging in age from 51 to 65 years. Postoperative signs of infection developed in the patients 4 to 15 days after surgery. In all five cases, cultures of aqueous or vitreous grew A. fumigatus. CONCLUSION Aspergillus endophthalmitis is a serious and devastating complication of ocular surgery. The outbreak, herewith, may have been related to hospital construction. The infection can be prevented, notably, by proper maintenance of old, "sick" buildings and by following certain procedures during hospital construction.
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Affiliation(s)
- K F Tabbara
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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15
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Lortholary O, Dupont B. Antifungal prophylaxis during neutropenia and immunodeficiency. Clin Microbiol Rev 1997; 10:477-504. [PMID: 9227863 PMCID: PMC172931 DOI: 10.1128/cmr.10.3.477] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Fungal infections represent a major source of morbidity and mortality in patients with almost all types of immunodeficiencies. These infections may be nosocomial (aspergillosis) or community acquired (cryptococcosis), or both (candidiasis). Endemic mycoses such as histoplasmosis, coccidioidomycosis, and penicilliosis may infect many immunocompromised hosts in some geographic areas and thereby create major public health problems. With the wide availability of oral azoles, antifungal prophylactic strategies have been extensively developed. However, only a few well-designed studies involving strict criteria have been performed, mostly in patients with hematological malignancies or AIDS. In these situations, the best dose and duration of administration of the antifungal drug often remain to be determined. In high-risk neutropenic or bone marrow transplant patients, fluconazole is effective for the prevention of superficial and/or systemic candidal infections but is not always able to prolong overall survival and potentially selects less susceptible or resistant Candida spp. Primary prophylaxis against aspergillosis remains investigative. At present, no standard general recommendation for primary antifungal prophylaxis can be proposed for AIDS patients or transplant recipients. However, for persistently immunocompromised patients who previously experienced a noncandidal systemic fungal infection, prolonged suppressive antifungal therapy is often indicated to prevent a relapse. Better strategies for controlling immune deficiencies should also help to avoid some potentially life-threatening deep mycoses. When prescribing antifungal prophylaxis, physicians should be aware of the potential emergence of resistant strains, drug-drug interactions, and the cost. Well-designed, randomized, multicenter clinical trials in high-risk immunocompromised hosts are urgently needed to better define how to prevent severe invasive mycoses.
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Affiliation(s)
- O Lortholary
- Service de Médecine Interne, Hôpital Avicenne, Université Paris-Nord, Bobigny, France
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16
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De Pauw BE. Practical modalities for prevention of fungal infections in cancer patients. Eur J Clin Microbiol Infect Dis 1997; 16:32-41. [PMID: 9063672 DOI: 10.1007/bf01575119] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Invasive fungal infections have become a major obstacle to the treatment of patients with malignancies. Candida spp. and Aspergillus spp. now rank among the ten most prominent pathogens in these patients. Currently, there are no adequate means of detecting these infections at an early stage, and optimal hygiene and elimination of well-known sources of infection remain the most important preventive measures. Due to the lack of reliable, randomized studies, the role of antifungal drugs in the prevention of invasive fungal infections is difficult to judge. The clinical impact of the older oral antifungal agents is questionable, and compliance with therapeutic regimens of these drugs is often limited. In prospective studies in bone marrow transplant recipients, fluconazole was effective in preventing candidiasis but offered no prophylaxis against infections due to Aspergillus spp. and other molds. Initial trials on the use of sprays and aerosols of amphotericin B and on infusions of low doses of this drug appeared beneficial, but the number of patients included was too small to allow any definite conclusion. Itraconazole offers promise, but it can only be given orally; adequate, reliable absorption is not yet guaranteed. While the lack of data justifies a wait-and-see approach in patients at low or moderate risk of developing a fungal infection, it seems reasonable to administer prophylaxis to high-risk patients, even though there is presently no single agent suitable for all prophylactic purposes.
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Affiliation(s)
- B E De Pauw
- Division of Hematology, University Hospital Nijmegen, The Netherlands
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18
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Briegel J, Forst H, Spill B, Haas A, Grabein B, Haller M, Kilger E, Jauch KW, Maag K, Ruckdeschel G. Risk factors for systemic fungal infections in liver transplant recipients. Eur J Clin Microbiol Infect Dis 1995; 14:375-82. [PMID: 7556225 DOI: 10.1007/bf02114892] [Citation(s) in RCA: 82] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The risk factors for systemic fungal infections were analysed retrospectively in 186 orthotopic liver transplant procedures performed in 152 patients between June 1985 and January 1993. The total incidence of systemic fungal infections was 16.5% (25/152). The incidence of disseminated candidiasis, aspergillosis, and combined candidiasis and aspergillosis was 6.5% (n = 10), 7.2% (n = 11) and 2.6% (n = 4), respectively. Mortality associated with systemic fungal infections was 80% (20 of 25 patients). There were ten cases of disseminated candidiasis, with 4 patients surviving, and 11 cases of invasive aspergillosis, with 1 patient surviving. All patients with combined systemic fungal infection died. To identify perioperative risk factors, 39 variables were used to compare patients with systemic fungal infections versus those without fungal infections. Fourteen variables were significantly associated with systemic fungal infections by univariate analysis. A consecutive logistic regression analysis revealed that the amount of fresh frozen plasma transfused due to poor initial function of the allograft and acute renal failure requiring hemofiltration were independently significant risk factors for systemic fungal infections. There was no statistical correlation between systemic fungal infections and the underlying liver disease, previous long-term corticosteroids and the postoperative immunosuppressive therapy. Risk factors identified in this study should be considered in the postoperative care of the individual liver transplant recipient. In our study a poor initial function of the hepatic allograft substantially increased the risk of systemic fungal infection.
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Affiliation(s)
- J Briegel
- Institut für Anaesthesíologie, Abteilung Medizinische Mikrobiologie, Ludwig-Maximilians-Universität München, Germany
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