Cutaneous and Bone Marrow Histoplasmosis After 18 Years of Renal Allograft Transplant

The frequency of histoplasmosis among solid organ transplant (SOT) recipients appears to be low where there are only a few case series, mostly among renal and liver transplant recipients. Herein we report a case of a 44-year-old woman who underwent a living-related renal transplant 18 years prior to evaluation, developed a nodule after followed by ulceration upon her posterior right leg and a second one upon her left leg 3 months and 2 months before her hospitalisation, respectively. The biopsy of lesion revealed the presence of Histoplasma spp. Bone marrow aspiration was performed and also revealed the same organism. She had initially received itraconazole without improvement of lesions, while a new lesion appeared on her left arm. Healing of all lesions could be observed after 40 days of liposomal amphotericin B when she was submitted to skin grafts on the legs and a surgical treatment on the arms, and the myelosuppression improved simultaneously. Histoplasmosis seems to be very uncommon among patients who underwent to organ solid transplantation. Most cases occur within 12–18 months after transplantation, although unusual cases have been presented many years post-transplant. There are cases reported in the literature, occurring from 84 days to 18 years after organ transplantation, but without cutaneous involvement. Our patient developed lesions on limbs and myelosuppression after 18 years of chronic immunosuppression medication. This case suggests that besides cutaneous histoplasmosis is an uncommon infection following iatrogenic immunosuppression and even rarer over a long period after the transplantation. Clinicians who care SOT recipient patients must bear in mind histoplasmosis infection as differential diagnosis in any case of cutaneous injury with prolonged fever and try to use as many tools as possible to make the diagnosis, once this disease presents a good prognosis if it is diagnosed and treated promptly.     

Lung Transplantation for Lymphangioleiomyomatosis in Japan

Background

Lung transplantation has been established as the definitive treatment option for patients with advanced lymphangioleiomyomatosis (LAM). However, the prognosis after registration and the circumstances of lung transplantation with sirolimus therapy have never been reported.

Methods

In this national survey, we analyzed data from 98 LAM patients registered for lung transplantation in the Japan Organ Transplantation Network.

Results

Transplantation was performed in 57 patients as of March 2014. Survival rate was 86.7% at 1 year, 82.5% at 3 years, 73.7% at 5 years, and 73.7% at 10 years. Of the 98 patients, 21 had an inactive status and received sirolimus more frequently than those with an active history (67% vs. 5%, p<0.001). Nine of twelve patients who remained inactive as of March 2014 initiated sirolimus before or while on a waiting list, and remained on sirolimus thereafter. Although the statistical analysis showed no statistically significant difference, the survival rate after registration tended to be better for lung transplant recipients than for those who awaited transplantation (p = 0.053).

Conclusions

Lung transplantation is a satisfactory therapeutic option for advanced LAM, but the circumstances for pre-transplantation LAM patients are likely to alter with the use of sirolimus.     

Viral infections in renal allograft recipients treated with long-term immunosuppression.

Thirty-nine renal allograft recipients who had received continuous immunosuppression for six to 13 years were examined clinically and virologically for evidence of past or present viral infection. Twenty-five had common warts, usually on the hands. In most the warts had appeared about one year after transplantation; once present, they never disappeared. Six patients had had a zoster rash from two months to four years after transplantation. None had had jaundice, and there was no change in the frequency of colds or non-specific fibrile illness. Four patients had no cytomegalovirus complement-fixing antibodies throughout the observation period; in the other 35 the antibody titre had risen appreciably during the first three to four months after transplantation. Antibody titres were high (mean 64) at follow-up, being only slightly lower than the highest titres achieved during the immediate postoperative period. None of the patients had had symptomatic cytomegalovirus infection, and in only two was the virus isolated from the urine at follow-up; the titres were extremely low. No changes occurred in the frequency of herpes simplex eruptions. Although all patients had herpes simplex humoral antibody, none excreted the virus. Although cytomegalovirus antibody titres were high, virus excretion was rare, indicating that chronic cytomegalovirus infection in these patients is immunologically well controlled.     

Long-term survival after orthotopic and heterotopic cardiac transplantation.

Five long-term survivors of heart transplantation were reinvestigated. Two patients had undergone orthotopic heart transplantation over 11 and 9 years earlier and constitute two of the world''s longest-surviving patients after this procedure. Three patients had undergone heterotopic heart transplantation (one left heart bypass alone and two biventricular bypass) four to six years earlier. Four of the five patients had had only one or no documented acute rejection episodes. Three had been given blood transfusions. None had had particularly good tissue matching in relation to the donor on HLA typing. All five patients were leading full and active lives. At review two patients had significant coronary artery disease, one severe, presumably due to chronic immune-complex deposition. Heart transplantation remains a major undertaking, but it can offer the patient many years of good-quality life.     

Cognitive function and behavioural status in paediatric heart and heart-lung transplant recipients: the Harefield experience.

OBJECTIVE--To assess the psychological impact of cardiac and cardiopulmonary transplantation on children. DESIGN--Retrospective cross sectional study. SETTING--One British centre performing paediatric heart and heart-lung transplant operations, four cardiac units in London, three London schools, two London health centres, and the dental department of a London children''s hospital. SUBJECTS--65 children who had been given heart or heart-lung transplants and two reference groups of 52 children who had had other types of cardiac surgery and 45 healthy children. MAIN OUTCOME MEASURES--Development, cognition, and behaviour at home and at school as assessed by measures with proved validity and reliability. RESULTS--Developmental and cognitive measures indicated that children given transplants had significantly lower scores on several parameters, particularly in terms of development in children under 4 1/2 years of age. Performance on all tests, however, was within the normal range. There were no significant differences in behavioural ratings between the transplant and reference groups, though problem behaviour at home was more prevalent in the transplant group. CONCLUSIONS--Though cognitive development may be within the normal range, there are adverse psychological effects associated with cardiac and cardiopulmonary transplantation. These data indicate the need for a controlled prospective study in which children and their families are seen before and at regular intervals after transplantation. Interventions should be developed that are tailored to the particular needs of this very specialised group of paediatric patients and their families.     

Disinfecting endoscopes: how not to transmit Mycobacterium tuberculosis by bronchoscopy.

Mycobacterium tuberculosis was cultured from the bronchial washings of two patients who underwent bronchoscopy consecutively with the same bronchoscope. Active pulmonary tuberculosis was later confirmed in the first patient, whereas the second patient had clinical and serologic evidence of infection with respiratory syncytial virus. The bronchoscope had been cleaned with an iodophor disinfectant, which had not destroyed the tubercle bacilli. The agent recommended for chemical disinfection of fibreoptic bronchoscopes is 2% glutaraldehyde solution; the instrument should be immersed in it for 10 to 30 minutes. Five hours'' exposure to ethylene oxide is recommended for sterilization of instruments. These procedures must be preceded by adequate mechanical cleaning. Then transmission of pathogenic organisms during endoscopy, which can result in nosocomial disease, misdiagnosis or inappropriate treatment, will be avoided.     

Liver transplantation in 100 children: Cambridge and King's College Hospital series.

To review the results of the Addenbrooke''s and King''s College Hospital children''s liver transplantation programme.Retrospective analysis of the first 100 children to receive liver grafts at Addenbrooke''s Hospital, Cambridge, from December 1983 to March 1990.Addenbrooke''s Hospital, Cambridge, and King''s College Hospital, London.153 children assessed for liver transplantation, of whom 22 died before a donor became available and 31 were considered unsuitable. 100 children received grafts, of whom 27 had second grafts.One year actuarial patient survival was 71%, with 57% one year graft survival. In the last two years survival rates had improved considerably, with 86% of patients and 63% of grafts surviving for at least one year. Sixty five children were alive 12 to 86 months after transplantation; 63 were well and leading normal active lives and 56 had entirely normal liver function. Children''s growth and development were essentially normal, with many showing remarkable catch up growth.Liver transplantation offers children with terminal liver disease a high chance of a return to full quality life and normal development. Improved surgical and medical care have progressively improved survival. The timing of transplantation is critical but has been constrained particularly by the availability of donors and resources.     

Radiological progression and lung function in silicosis: a ten year follow up study.

Chest radiographs and spirometric tests were performed on 81 patients who had silicosis from two granite quarries in 1975, 73 of whom were followed up for two to 10 (mean 7.2) years. Each patient''s initial and most recent chest radiographs were assessed independently by three experienced readers, and the yearly declines in forced expiratory volume in one second and forced vital capacity were estimated from two to four (mean 3.45) serial spirometric readings. Estimates of individual dust exposure were based on extensive historical data on hygiene. All but 11 patients were no longer exposed to dust by the start of follow up, but 24 (45%) of 53 patients who had simple silicosis and 11 (55%) of 20 who had the complicated disease showed radiological evidence of disease progression. In patients who had simple silicosis and showed no radiological progression the yearly declines in forced expiratory volume in one second and forced vital capacity were modest (64 ml/year and 59 ml/year, respectively), whereas significantly greater declines in lung function were seen in those who showed radiological evidence of progression (97 ml/year and 95 ml/year, respectively). In addition to radiological progression the previous average dust concentration to which patients had been exposed also influenced declines in both forced expiratory volume in one second and forced vital capacity after allowing for the effects of age, smoking, duration of exposure, history of tuberculosis, initial state of disease, and baseline lung function. The probability of radiological progression was most strongly influenced by the average dust concentration previously exposed to. The progression of simple silicosis is thus accompanied by appreciable declines in lung function and is strongly affected by previous levels of exposure to dust.     

Mortality in relation to smoking: 40 years' observations on male British doctors.

OBJECTIVE--To assess the hazards associated with long term use of tobacco. DESIGN--Prospective study of mortality in relation to smoking habits assessed in 1951 and again from time to time thereafter, with causes sought of deaths over 40 years (to 1991). Continuation of a study that was last reported after 20 years'' follow up (1951-71). SUBJECTS--34,439 British male doctors who replied to a postal questionnaire in 1951, of whom 10,000 had died during the first 20 years and another 10,000 have died during the second 20 years. RESULTS--Excess mortality associated with smoking was about twice as extreme during the second half of the study as it had been during the first half. The death rate ratios during 1971-91 (comparing continuing cigarette smokers with life-long non-smokers) were approximately threefold at ages 45-64 and twofold at ages 65-84. The excess mortality was chiefly from diseases that can be caused by smoking. Positive associations with smoking were confirmed for death from cancers of the mouth, oesophagus, pharynx, larynx, lung, pancreas, and bladder; from chronic obstructive pulmonary disease and other respiratory diseases; from vascular diseases; from peptic ulcer; and (perhaps because of confounding by personality and alcohol use) from cirrhosis, suicide, and poisoning. A negative association was confirmed with death from Parkinson''s disease. Those who stopped smoking before middle age subsequently avoided almost all of the excess risk that they would otherwise have suffered, but even those who stopped smoking in middle age were subsequently at substantially less risk than those who continued to smoke. CONCLUSION--Results from the first 20 years of this study, and of other studies at that time, substantially underestimated the hazards of long term use of tobacco. It now seems that about half of all regular cigarette smokers will eventually be killed by their habit.     

Cytomegalovirus disease as a possible etiologic factor for early atherosclerosis

A group of 284 patients who underwent orthotopic heart transplantation between April 1986 to June 1991 and who were followed up for at least five years was analyzed in this paper. Patients were divided into three groups according to the presence or absence of cytomegalovirus infection or disease: patients without infection, patients with serologycaly proven infection and patients with cytomegalovirus disease. The analysis of survival was performed with respect to all major factors that influence survival: age and sex of a donor and a recipient, number of rejection episodes, perioperative ischemic time and pulmonary vascular resistence. A recipient's age was shown to be a significant factor. Patients who experienced at least one episode of cytomegalovirus disease had significantly worse long-term survival compared to those with the infection only or without the infection. That difference was caused by the increased incidence of coronary atherosclerosis, which caused deaths in patients with a previous episode of cytomegalovirus disease. A possible mechanism responsible for this phenomenon is discussed.     

Pulmonary Alveolar Proteinosis—Review of the Literature with Follow-up Studies and Report of Two New Cases

In the period from 1958, when Rosen and coworkers first reported a condition in which the pulmonary alveoli are filled with an eosinophilic material, to the beginning of 1964, reports of 93 cases had accumulated in the world literature, including two cases included herein. The cause of this disease, which Rosen called “pulmonary alveolar proteinosis,” is not known, nor is there a known means of cure.The usual patient is a white man between 30 and 50 years of age who may do any kind of work. The first symptoms may be those of pulmonary infection or pulmonary insufficiency. Patients with pulmonary alveolar proteinosis are prone to nocardiosis and infection with other fungi. Diagnosis is made by lung biopsy.Twenty of the 93 patients reported upon were alive at the time of this review, 37 were dead and 36 had been lost to follow-up.     

Case-control study of leukaemia and non-Hodgkin's lymphoma among children aged 0-4 years living in west Berkshire and north Hampshire health districts.

OBJECTIVE--To investigate the relation between parental employment in the nuclear industry and childhood leukaemia and non-Hodgkin''s lymphoma. DESIGN--Case-control study. SETTING-West Berkshire and Basingstoke and North Hampshire District Health Authorities. SUBJECTS--54 children aged 0-4 years who had leukaemia or non-Hodgkin''s lymphoma diagnosed during 1972-89, who were born in the study area and were resident there when cancer was diagnosed. Six controls were selected for each case: four from hospital delivery registers and two from livebirth registers maintained by the NHS central register. Controls were matched for sex, date of birth (within six months), and area of residence at birth and time of diagnosis. MAIN OUTCOME MEASURES--Parents'' employment by the nuclear industry and exposure to ionising radiation at work. RESULTS--Five (9%) of the 54 cases and 14 (4%) of the 324 controls had fathers or mothers, or both, who had been employed by the nuclear industry (relative risk 2.2, 95% confidence interval 0.6 to 6.9). Nuclear industry employees who work in areas where exposure to radiation is possible are given film badges to monitor their exposure to external penetrating ionising radiation. Three fathers of cases and two fathers of controls (and no mothers of either) had been monitored in this way before their child was conceived (relative risk 9.0, 95% confidence interval 1.0 to 107.8). No father (of a case or control) had accumulated a recorded dose of more than 5 mSv before his child was conceived, and no father had been monitored at any time in the four years before his child was conceived. A dose-response relation was not evident among fathers who had been monitored. CONCLUSIONS--These results suggest that the children of fathers who had been monitored for exposure to external penetrating ionising radiation in the nuclear industry may be at increased risk of developing leukaemia before their fifth birthday. The finding is based on small numbers and could be due to chance. If the relationship is real the mechanisms are far from clear, except that the effect is unlikely to be due to external radiation; the possibility that it could be due to internal contamination by radioactive substances or some other exposure at work should be pursued. The above average rates of leukaemia in the study area cannot be accounted for by these findings.     

Invasive pulmonary aspergillosis: retrospective case record review

Invasive pulmonary aspergillosis is a severe infection, with a sharp increase during the last decades. Our study aimed at identification of the epidemiological characteristics of invasive pulmonary aspergillosis during a period of four years. All clinical records with pulmonary isolation of Aspergillus species were reviewed, as a part of surveillance program at Reina Sofia University Hospital, from January 1995 to December 1998. Diagnosis of invasive pulmonary aspergillosis was based on criteria of Centers for Disease Control and Prevention. Of the 50 patients identified 78% were males and 44% were current or ex-smokers. Chronic respiratory diseases were identified in 64% of them, and 60% were receiving immunosuppressives. Twenty percent of our patients had been subjected to lung transplantation and 28% to organ transplantation in general. Only 78% had received specific antifungal treatment and 56% had fatal prognosis. Our findings match with previous studies, apart from the high frequency of lung transplantation in our series. We recommend further studies on large prospective cohorts.     

Use of the Deane prosthesis in patients on long-term peritoneal dialysis

The Deane peritoneal prosthesis has been used successfully in the treatment of 21 patients with chronic renal failure who were maintained on peritoneal dialysis for periods of up to 20 months. All patients were dialyzed for 24 hours twice weekly. While the prosthesis was still in place, transplantation was carried out in seven patients and laparotomy in three. The prosthesis was also used temporarily whenever a permanent peritoneal catheter (Tenckhoff''s) failed because of infection; it was used until the signs of infection disappeared, then the permanent catheter could be replaced safely. From a total of 1136 dialyses 36 positive cultures were reported. Clinical peritonitis was found on only four occasions.     

Chlamydia trachomatis infection in rural Nova Scotia.

OBJECTIVE: To examine the demographic characteristics of patients who underwent testing for Chlamydia trachomatis and to determine the clinical and behavioural characteristics and the types of treatment for those who had positive test results. DESIGN: Case series. SETTING: Rural county in Nova Scotia. PATIENTS: All residents of the county for whom testing for C. trachomatis was ordered at the regional hospital from Sept. 1, 1990, to Mar. 31, 1991. MAIN OUTCOME MEASURES: Rates of testing and of positive test results by age and sex. Comparison of patient and physician characteristics in relation to testing rates. RESULTS: Of the 1116 patients tested 58 (5.2%) had positive test results. Females accounted for 82.8% of those with positive results whose sex could be determined. Among the females the mean age of those with a positive result was 22.3 years, as compared with 27.5 years for those with a negative result (p < 0.0001). Females 15 to 19 years of age were less likely to have a test performed than women 20 to 29 years and were more likely to have a positive test result than the women in the older groups. Almost 9% of the testing among the females was in those over 39 years of age, although no infection was seen in this age group. The number of tests ordered per general or family practitioner varied from 1 to 154; the physicians'' sex, practice location and length of time in practice did not predict the rates of positive test results. Treatment was most often in keeping with that recommended by national guidelines. Four (8.5%) of the 47 patients with positive results who were interviewed were not aware of their diagnosis, either because they had not returned for follow-up or had not being notified by the physician''s office. CONCLUSIONS: The frequency of testing for C. trachomatis infection may be less than is desirable among young patients, who, if tested, are more likely than older patients to have positive results. More understanding of the diagnostic approach taken by physicians is needed.     

Phenotypic and molecular identification of Coccidioides posadasii in a patient evaluated for bilateral lung transplantation

BackgroundCoccidioidomycosis is an endemic fungal infection caused by Coccidioides immitis and Coccidioides posadasii. It can be particularly severe in transplant recipients that have a current or a previous coccidioidal infection. Fatal case of coccidioidomycosis has been described in this group of patients.AimsWe report a severe case of pneumonia caused by C. posadassi in a 29 year-old white woman that had been admitted to hospital as part of the evaluation for bilateral lung transplantation. The patient was a native and resident of Catamarca, Argentina. Molecular methodologies contributed to the species identification.MethodsClinical, laboratory records and microbiological tests were carried out to diagnose the infection and to identify C. posadasii.ResultsA fungus was isolated from BAL culture. Phenotypic characterization, specific PCR and experimental animal inoculation demonstrated the presence of C. posadasii. The patient responded well to amphotericin B deoxycholate. Lung transplantation was postponed.ConclusionsSpecific PCR can be an important alternative for the correct identification of C. immitis or C. posadasii in laboratories with implemented molecular biology tools. This case emphasizes the need for a systematic assessment in organ transplant units of patients inhabiting endemic areas of coccidioidomycosis.     

De novo acute infection and reactivation of hepatitis B virus in established cirrhosis.

Five patients with cirrhosis proved by biopsy had clinical, biochemical, and serological evidence of an acute hepatitis B infection. In two the illness was fulminant and led to death. Only one patient completely recovered. Serological markers for the hepatitis B virus were absent before the onset of the acute illness in four patients, which suggested that a de novo infection had been acquired as a result of recent transfusions of blood or blood products. The fifth patient, who had Goodpasture''s syndrome, had antibody to the core of hepatitis B virus, indicating previous exposure to the virus; his acute hepatitis may have been related to immunosuppressive drug treatment, which may have reactivated a dormant virus infection. Thus an acute type B viral hepatitis due to either a de novo or a reactivated infection may be superimposed on cirrhosis.     

Psychometric Properties of the Lexington Attachment to Pets Scale: Mexican Version (LAPS-M)

The Lexington Attachment to Pets Scale (LAPS) is perhaps the most widely used instrument to assess human emotional attachments to pets and is suitable for both dog and cat owners. However, this instrument has not been translated into Spanish. Thus, the present study aimed to assess the psychometric properties of the Mexican version of the Lexington Attachment to Pets Scale (LAPS-M), which was translated into Spanish and adapted for dog owners. We analyzed the internal consistency and factor structure in a convenience sample of 152 people; 56.6% were women and 43.4% were men, with a mean age of 32.4 years (SD = 10.9 years), who had, on average, two dogs for a period of 3.8 years. The results indicate that the scale has excellent internal consistency in its complete version, with a Cronbach's alpha of 0.96, and also in its three subscales, with Cronbach's alpha coefficients ranging from 0.83 to 0.94. Factor analysis suggests a unifactorial structure is appropriate. However, the goodness-of-fit indicated by confirmatory factor analysis statistics would likely improve with a larger sample size. When we compared the central tendency measures of the LAPS-M according to the type of relationship with the dog, we found higher scores among people who considered dogs to be family members than among those who considered dogs to be pets. Furthermore, people who reported that the relationship with their dog was burdensome or stressful had lower scores. We conclude that the Mexican version of the LAPS is adequate and that further studies with larger sample sizes will contribute to the evidence regarding its psychometric properties     

Nd-YAG Laser in Lung Cancer

We administered 45 Nd-YAG laser treatments in 29 patients (18 men) aged 39 to 82 years who had lung malignancy; 26 patients had primary non-oat cell lung cancer and three had metastatic airway malignancy. In all, 25 of the patients had been previously treated with combination(s) of surgical procedure, radiation therapy and chemotherapy. Indications for laser treatment included endobronchial airway obstruction with uncontrolled cough, hemoptysis, dyspnea or unresolved atelectasis-pneumonia. Of 15 patients with partially occluded tracheobronchial airway tumors, immediate palliative relief was achieved in 13 patients and lasted one to six months after a single treatment. In this group there was one postoperative death related to respiratory failure and two patients subsequently died of massive pulmonary hemorrhage. However, of 14 patients with totally obstructed airways, immediate palliative relief was achieved in only five patients and this lasted three weeks to three months after a single treatment. In this group there were two postoperative deaths related to progressive respiratory failure; in one case it was associated with endobronchial combustion of the fiberoptic bronchoscope. All three patients in both groups who died of respiratory failure were in acute respiratory distress and terminally ill before the procedure. These findings suggest that Nd-YAG laser therapy may be most beneficial in patients with partially rather than totally occluded airways due to lung malignancy.