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Z Gastroenterol 2014; 52(8): 813-817
DOI: 10.1055/s-0034-1366647
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© Georg Thieme Verlag KG Stuttgart · New York

Invasive Cardiac Aspergillosis after Orthotopic Liver Transplantation

Invasive kardiale Aspergillose nach orthotoper Lebertransplantation
G. Wiltberger
1   Department of Visceral, Transplantation, Thorax and Vascular Surgery, University of Leipzig, Leipzig, Germany
,
M. Schmelzle
1   Department of Visceral, Transplantation, Thorax and Vascular Surgery, University of Leipzig, Leipzig, Germany
2   Translational Centre for Regenerative Medicine, University of Leipzig, Germany
,
S. Schubert
3   Department of Medicine, Dermatology and Neurology, Division of Infectious Diseases and Tropical Medicine, Clinic of Gastroenterology and Rheumatology, University of Leipzig, Leipzig, Germany
,
C. Lübbert
3   Department of Medicine, Dermatology and Neurology, Division of Infectious Diseases and Tropical Medicine, Clinic of Gastroenterology and Rheumatology, University of Leipzig, Leipzig, Germany
,
P. Brandmaier
4   Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany
,
T. Berg
3   Department of Medicine, Dermatology and Neurology, Division of Infectious Diseases and Tropical Medicine, Clinic of Gastroenterology and Rheumatology, University of Leipzig, Leipzig, Germany
,
D. Pfeiffer
5   Department of Medicine, Dermatology and Neurology, Division of Cardiology and Angiology, University of Leipzig, Leipzig, Germany
,
A. Rodloff
6   Institute for Medical Microbiology and Epidemiology of Infectious Diseases, University of Leipzig, Leipzig, Germany
,
F.-W. Mohr
7   Department of Cardiac Surgery, University of Leipzig, Leipzig, Germany
,
S. Jonas
1   Department of Visceral, Transplantation, Thorax and Vascular Surgery, University of Leipzig, Leipzig, Germany
› Author Affiliations
Further Information

Publication History

23 March 2014

09 May 2014

Publication Date:
11 August 2014 (online)

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Abstract

Invasive aspergillus infection occurs in 5 – 42 % of liver-transplanted recipients and is a dangerous complication, associated with high mortality if untreated. However, the early diagnosis of invasive aspergillosis can be elusive, as clinical signs are unspecific and the pathogenic agent is difficult to demonstrate. We here report about a 58-year-old man with acute liver failure caused by newly diagnosed chronic hepatitis B infection who underwent liver transplantation. The postoperative course was uneventful, and the patient was discharged after 30 days. After 105 days the patient was readmitted because of fever, recurrent chest and abdominal pain. Computed tomography revealed a cardiac lesion; other diagnostic steps including bone-marrow and endomycordial biopsy, virological and microbiological investigations gave no clear findings. To exclude a malignant process, thoracotomy with mass and simultaneous lower left lobe resection were performed. Histopathological findings revealed an invasive perimyocardial aspergillosis. Immediate intravenous therapy with voriconazole and caspofungin was initiated and monitoring of the mass was performed with transesophageal echocardiography and Cardio-MRI. Due to slightly increase of the lesion, medication was switched to posaconazole and caspofungin. Under this dual fungal treatment the lesion regressed and the patient could be discharged after two months in good clinical condition. Frequent Cardio-MRI scan after discharge showed further mass-regression. Therefore antifungal treatment was switched to oral posaconazole mono-therapy. After one year, complete reduction of the mass was achieved and antifungal therapy was discontinued. Recent diagnostic imaging follow-up showed no pathological finding.

Zusammenfassung

Eine invasive Aspergillus-Infektion tritt bei 5 – 42 % der lebertransplantierten Patienten auf und ist eine ernst zu nehmende Komplikation, welche unbehandelt mit einer hohen Mortalität einhergeht. Zusätzlich ist die frühzeitige Diagnose der invasiven Aspergillose erschwert, da klinische Symptome unspezifisch und die Erreger nur schwer nachweisbar sind. Wir berichten hier über einen 58-jährigen Mann mit akutem Leberversagen bei neu diagnostizierter chronischer Hepatitis-B-Infektion, welcher zeitnah einer Lebertransplantation zugeführt werden konnte. Der postoperative Verlauf war komplikationslos und der Patient konnte nach 30 Tagen entlassen werden. Nach 105 Tagen wurde der Patient aufgrund von Fieber, wiederkehrenden Brust- und Bauchschmerzen erneut stationär aufgenommen. In der durchgeführten Computertomografie zeigte sich eine unklare Läsion im Myokard, andere Untersuchungen einschließlich Knochenmarks- und endomyokardialer Biopsie, virologische und mikrobiologische Untersuchungen ergaben keinen eindeutigen Befund. Um einen malignen Prozess auszuschließen, wurde eine Thorakotomie mit Entfernung der unklaren Raumforderung mit gleichzeitiger Resektion des linken Unterlappens durchgeführt. Histologisch ergab sich hier eine perimyokardiale invasive Aspergillose. Eine sofortige intravenöse Therapie mit Voriconazol und Caspofungin wurde initiiert und Verlaufskontrollen mittels transösophagealer Echokardiografie und Kardio-MRT durchgeführt. Aufgrund einer weiteren Größenzunahme der Läsion, wurde die Therapie auf Posaconazol und Caspofungin umgestellt. Unter dieser dualen antifungalen Behandlung zeigte sich ein deutlicher Rückgang der Läsionen und der Patient konnte nach 2 Monaten im guten klinischen Zustand entlassen werden. Die ambulanten Verlaufskontrollen mittels Kardio-MRT zeigten einen weiteren Regress der Läsionen. Daher wurde die antimykotische Behandlung auf eine orale Posaconazol-Monotherapie umgestellt. Nach einem Jahr zeigt sich eine vollständige Auflösung der Läsion und die antimykotische Therapie wurde beendet. Ein kürzlich durchgeführtes Follow-up ergab kein Anhalt auf einen erneuten pathologischen Befund.

Schlüsselwörter

Leber - Transplantation - Hepatitis B - Aspergillose

Key words

liver - transplantation - hepatitis B - aspergillosis
 

  • References

  • 1 Lock J, Reinhold T, Bloch A et al. The cost of graft failure and other severe complications after liver transplantation – experience from a German Transplant Center. Ann Transplant 2010; 15: 11-18
    PubMedGoogle Scholar
  • 2 Rahbari NN, Mehrabi A, Mollberg NM et al. Hepatocellular carcinoma: current management and perspectives for the future. Ann Surg 2011; 253: 453-469
    CrossrefPubMedGoogle Scholar
  • 3 Zhou T, Xue F, Han LZ et al. Invasive fungal infection after liver transplantation: risk factors and significance of immune cell function monitoring. J Dig Dis 2011; 12: 467-475
    CrossrefPubMedGoogle Scholar
  • 4 Singh N, Wagener MM, Cacciarelli TV et al. Antifungal management practices in liver transplant recipients. Am J Transplant 2008; 8: 426-431
    CrossrefPubMedGoogle Scholar
  • 5 Lie TS, Hofer M, Hohnke C et al. Aspergillosis following liver transplantation as a hospital infection. Dtsch Med Wochenschr 1987; 112: 297-301
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 San-Juan R, Aguado JM, Lumbreras C et al. Universal prophylaxis with fluconazole for the prevention of early invasive fungal infection in low-risk liver transplant recipients. Transplantation 2011; 92: 346-350
    CrossrefPubMedGoogle Scholar
  • 7 Winston DJ, Busuttil RW. Randomized controlled trial of oral itraconazole solution versus intravenous/oral fluconazole for prevention of fungal infections in liver transplant recipients. Transplantation 2002; 74: 688-695
    CrossrefPubMedGoogle Scholar
  • 8 Pappas PG, Alexander BD, Andes DR et al. Invasive fungal infections among organ transplant recipients: results of the Transplant-Associated Infection Surveillance Network (TRANSNET). Clin Infect Dis 2010; 50: 1101-1111
    CrossrefPubMedGoogle Scholar
  • 9 Neofytos D, Fishman JA, Horn D et al. Epidemiology and outcome of invasive fungal infections in solid organ transplant recipients. Transpl Infect Dis 2010; 12: 220-229
    CrossrefPubMedGoogle Scholar
  • 10 Linden PK, Coley K, Fontes P et al. Invasive aspergillosis in liver transplant recipients: outcome comparison of therapy with amphotericin B lipid complex and a historical cohort treated with conventional amphotericin B. Clin Infect Dis 2003; 37: 17-25
    CrossrefPubMedGoogle Scholar
  • 11 Husain S, Tollemar J, Dominguez EA et al. Changes in the spectrum and risk factors for invasive candidiasis in liver transplant recipients: prospective, multicenter, case-controlled study. Transplantation 2003; 75: 2023-2029
    CrossrefPubMedGoogle Scholar
  • 12 Grauhan O, Lohmann R, Lemmens P et al. Fungal infections in liver transplant recipients. Langenbecks Arch Chir 1994; 379: 372-375
    PubMedGoogle Scholar
  • 13 Eschenauer GA, Lam SW, Carver PL. Antifungal prophylaxis in liver transplant recipients. Liver Transpl 2009; 15: 842-858
    CrossrefPubMedGoogle Scholar
  • 14 Rosenhagen M, Feldhues R, Schmidt J et al. A risk profile for invasive aspergillosis in liver transplant recipients. Infection 2009; 37: 313-319
    CrossrefPubMedGoogle Scholar
  • 15 Kusne S, Torre-Cisneros J, Manez R et al. Factors associated with invasive lung aspergillosis and the significance of positive Aspergillus culture after liver transplantation. J Infect Dis 1992; 166: 1379-1383
    CrossrefPubMedGoogle Scholar
  • 16 De Pauw B, Walsh TJ, Donnelly JP et al. Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group. Clin Infect Dis 2008; 46: 1813-1821
    CrossrefPubMedGoogle Scholar
  • 17 Guinea J, Garcia de Viedma D, Pelaez T et al. Molecular epidemiology of Aspergillus fumigatus: an in-depth genotypic analysis of isolates involved in an outbreak of invasive aspergillosis. J Clin Microbiol 2011; 49: 3498-3503
    CrossrefPubMedGoogle Scholar
  • 18 Denning DW, Ribaud P, Milpied N et al. Efficacy and safety of voriconazole in the treatment of acute invasive aspergillosis. Clin Infect Dis 2002; 34: 563-571
    CrossrefPubMedGoogle Scholar
  • 19 Lellek H, Waldenmaier D, Dahlke J et al. Caspofungin plus posaconazole as salvage therapy of invasive fungal infections in immunocompromised patients. Mycoses 2011; 54 Suppl 1: 39-44
    PubMedGoogle Scholar