Aspergilosis pulmonar invasora en pacientes pediátricos con trasplante hepático, a propósito de una sobreviviente / Invasive pulmonary aspergillosis in children with hepatic transplant: a survivor

INTRODUCCIÓN: Las infecciones por Aspergillus spp son la principal infección micótica por hongos en pacientes con trasplante hepático, con una mortalidad reportada de hasta un 90% de los casos. En los pacientes trasplantados de hígado se espera que hasta un 50% desarrollen un episodio infeccioso en sus primeros meses postrasplante, de los cuales un 10% se asocian con agentes oportunistas. OBJETIVO: Describir el diagnóstico y manejo de un episodio de Aspergilosis Pulmonar Invasora (API) en una paciente con un trasplante hepático CASO CLÍNICO: Paciente de 11 meses de vida, con trasplante hepático secundario a atresia de vías biliares. En el periodo post-trasplante inmediato evolucionó con una neumonía grave asociada a ventilación mecánica. El lavado broncoalveolar presentó niveles altos de galactomanano y cultivo positivo para Aspergillus fumigatus, diagnosticándose una API. Este episodio se trató con un esquema de antifúngico con un resultado clínico favorable. CONCLUSIÓN: La API es una infección oportunista en pacientes con trasplante hepático, que debe ser sospechada en este grupo de pacientes, ya que el diagnóstico y tratamiento oportuno impacta directamente en la resolución de la infección por Aspergillus fumigatus.

INTRODUCTION: Mycotic infections due to Aspergillus spp, are the main mycotic associated infections in liver transplant patients, with mortality rates up to 90% of the cases. Almost 50% of patients will de velop an infection during the first months after transplantation, of which 10% are associated with op portunistic agents. OBJECTIVE: To describe the diagnosis and management of an Invasive Pulmonary Aspergillosis (IPA) episode in a liver transplant patient. CASE-REPORT: 11-months-old patient with liver transplant due to a biliary atresia who developed severe pneumonia associated with mechanical ventilation. The bronchoalveolar lavage showed high levels of galactomannan and positive culture for Aspergillus fumigatus leading to an IPA diagnosis. This episode was treated with antifungal with a favorable outcome. CONCLUSION: The IPA is an opportunistic infection in liver transplant patients, with high mortality rates, that must be suspected in this group of patients since an early diagnosis and treatment reduce mortality.

The importance of risk factors for the prediction of patients with invasive pulmonary aspergillosis

Summary Objective: Invasive pulmonary aspergillosis (IPA) is a major challenge in the management of immunocompromised patients. Despite all the advances in diagnosis, it remains a problem. The purpose of our study was to investigate the risk factors associated with IPA seen in patients with hematological malignancies. Method: A total of 152 febrile neutropenia (FEN) patients with hematological malignancies aged over 18 years and receiving high-dose chemotherapy or stem cell transplant between January 1, 2010, and December 31, 2012 were included in the study. Sixty-five (65) cases with IPA according to the European Organization for the Research and Treatment of Cancer and Infectious Diseases Mycoses Study Group criteria were enrolled as the case group, while 87 patients without IPA development during concomitant monitoring were enrolled as the control group. Incidence of IPA was 21.4% (3/14) in patients receiving bone marrow transplant (allogeneic 2, autologous 1) and those cases were also added into the case group. The two groups were compared in terms of demographic, clinical and laboratory findings and risk factors associated with IPA investigated retrospectively. Results: Presence of relapse of primary disease, neutropenia for more than 3 weeks, presence of bacterial infection, and non-administration of antifungal prophylaxis were identified as risk factors associated with IPA. Conclusion: It may be possible to reduce the incidence of the disease by eliminating preventable risk factors. Predicting those risks would, per se, enable early diagnosis and treatment and, thus, the mortality rate of these patients would unquestionably decline.

Aspergilosis invasora pulmonar en paciente con leucemia mieloide aguda en quimioterapia / Invasive pulmonary aspergillosis in patients with leukemia acute myeloid chemotherapy

Se reporta un caso clínico de un paciente masculino de 65 años, que ingresó al hospital por cuadro de 10 días de evolución, con sospecha clí- nica y de laboratorio de un síndrome mieloproliferativo. Estudiado por hematología, se confirmó Leucemia Mieloide Aguda M5. Se inició quimioterapia de inducción. El paciente evolucionó con pancitopenia, destacando neutropenia severa hasta 200 /mm3, febril y sin foco precisado. Se trató con antibióticos de amplio espectro por 10 días con buena respuesta. Cinco días después de finalizar su tratamiento antibiótico, nuevamente comenzó con fiebre, alza de parámetros inflamatorios, neutropenia severa y clínica de foco respiratorio. Se realizó Tomografía Computada (TC) de tórax y galactomanano en sangre, ambos compatibles con aspergilosis pulmonar, por lo que se inició tratamiento con voriconazol. El paciente evolucionó con buena respuesta clínica y de laboratorio, mejoría de imá- genes del TC de tórax y negativización de galactomanano. Al mes cedió la pancitopenia. Fue dado de alta en buenas condiciones generales, con indicación de volver a hospitalizar para quimioterapia de consolidación.

A report of a clinical case of a male patient aged 65 is presented. He entered to the hospital for 10 days evolution box with clinical and laboratory suspicion of a myeloproliferative syndrome. Studied by hematology, acute myeloid leukemia M5 was confirmed. induction chemotherapy began. The patient developed pancytopenia, highlighting severe neutropenia up to 200 / mm3, fever and without pointed focus. He was treated with broadspectrum antibiotics for 10 days with good response. Five days after finishing his antibiotic treatment began with fever again, rising inflammatory parameters, neutropenia and severe respiratory clinical focus. Computed Tomography (CT) of the chest and blood galactomannan was realized, both were compatible with pulmonary aspergillosis, starting treatment with voriconazole. The patient developed good both clinical and laboratory, improvement in chest CT images and negativization galactomannan response. Month later yielded pancytopenia. He was discharged in good general condition, indicating again been hospitalized for consolidation chemotherapy.

Acute invasive pulmonary aspergillosis, shortly after occupational exposure to polluted muddy water, in a previously healthy subject / Aspergilose pulmonar invasiva aguda, logo após exposição ocupacional a água poluída barrenta, em indivíduo previamente saudável

Invasive pulmonary aspergillosis (IPA) predominantly occurs in severely neutropenic immunocompromised subjects. The occurrence of acute IPA after brief but massive exposure to Aspergillus conidia in previously healthy subjects has been documented, although only six such cases have been reported. The diagnosis was delayed in all six of the affected patients, five of whom died. We report the case of a 50-year-old HIV-negative male, a water pipeline maintenance worker, who presented with acute-onset dyspnea and fever one day after working for 2 h in a deep pit containing polluted, muddy water. Over a one-month period, his general condition deteriorated markedly, despite antibiotic therapy. Imaging showed bilateral diffuse nodules with cavitation, some of which were surrounded by ground-glass opacity suggestive of a halo sign (a hallmark of IPA). Cultures (of sputum/bronchial aspirate samples) and serology were positive for Aspergillus fumigatus. After being started on itraconazole, the patient improved. We conclude that massive exposure to Aspergillus conidia can lead to acute IPA in immunocompetent subjects.

A aspergilose pulmonar invasiva (API) ocorre predominantemente em indivíduos imunocomprometidos com neutropenia grave. A ocorrência de API aguda após exposição breve, mas maciça, a conídios de Aspergillus sp. em indivíduos previamente saudáveis já foi documentada, embora apenas seis casos tenham sido relatados. O diagnóstico foi tardio em todos os seis pacientes afetados, dos quais cinco foram a óbito. Relatamos o caso de um homem de 50 anos de idade, HIV negativo, trabalhador de manutenção de tubulação de água, que apresentou dispneia e febre de início agudo um dia após trabalhar 2 h em uma vala funda contendo água poluída e barrenta. Num período de um mês, seu estado geral se deteriorou acentuadamente, apesar da antibioticoterapia. Exames de imagem mostraram nódulos bilaterais difusos com cavitação, alguns dos quais circundados por opacidade em vidro fosco sugestiva de sinal do halo (uma característica da API). As culturas (de amostras de escarro/aspirado brônquico) e a sorologia foram positivas para Aspergillus fumigatus. Após iniciado o tratamento com itraconazol, o paciente melhorou. Concluímos que a exposição maciça a conídios de Aspergillus pode levar a API em indivíduos imunocompetentes.