Incidence of Early and Late-Onset Clostridioides difficile Infection following Appendectomy Compared to Other Common Abdominal Surgical Procedures.

Introduction: Clostridioides difficile associated diarrhea (CDAD) is a major public health issue. The appendix may function as a reservoir for the intestinal microbiome, which may repopulate the intestine following enteric infections including CDAD. Patients/Methods. This retrospective cohort study includes a total of 12,039 patients undergoing appendectomy, hemicolectomy, and cholecystectomy at a single center between 1992 and 2011 who were diagnosed with early and late-onset CDAD and were followed for a minimum of two years. Results: Cumulative CDAD rates were 2.3% after appendectomy, 6.4% after left and 6.8% after right hemicolectomy, and 4% after cholecystectomy with a median onset of 76 (range 1-6011) days after the procedure. Median time to CDAD onset was 76 days after appendectomy, 23 days after left, 54 days after right hemicolectomy, and 122 days after cholecystectomy (p < 0.05). Late-onset CDAD (>1 year) was significantly more common following appendectomy (37%) and cholecystectomy (39%) than after left (17%) and right (21%) hemicolectomy. Significant differences in age, gender, complication rate, and length of hospitalization between the four groups need to be considered when interpreting the results. Conclusion: The incidence of CDAD after various abdominal surgeries ranged between 2% and 7% in this study. Whereas, hemicolectomy patients had predominantly early onset CDAD, and appendectomy and cholecystectomy may increase the risk for late-onset CDAD. Appendectomy per se does not seem to increase the risk for late-onset CDAD.

Superior Sagittal Sinus Tumor Eroding through the Skull: An Unfamiliar Presentation of Hepatocellular Carcinoma and Literature Review.

BACKGROUND: Hepatocellular carcinoma (HCC) most commonly develops in patients with liver cirrhosis caused by hepatitis C and B virus. HCC is the most common cause of death in people with cirrhosis. The lungs, bone, and lymph nodes are frequent sites of metastasis of HCC. PATIENTS AND METHODS: We present a case of solitary skull metastasis as the first symptom of HCC. A literature review with regard to HCC skull metastasis was undertaken. RESULTS: This patient had HCC based on chronic hepatitis C. He presented with an erosive lesion masquerading as a scalp lipoma resulting in hepatocellular carcinoma with retrograde reflux and sinus metastases. The lesion was ultimately resected, but the patient died within one week from liver failure. Seventeen similar cases were found in the literature. Median age of the patients was 58 years with 95% being male and 35% having viral hepatitis. Surgery was the preferred treatment with chemotherapy and radiation being other options. Outcome was acceptable but baseline liver disease is a limiting factor. DISCUSSION: Cranial metastases of HCC are rare but should be considered in patients with chronic hepatitis C presenting with scalp skin lesions.

Post-transplant lymphoproliferative disorders are not associated with IgG4 sclerosing disease.

BACKGROUND: Although the majority of post-transplant lymphoproliferative disorder (PTLD) cases are associated with Epstein-Barr virus (EBV), 20-42% of cases are EBV negative (EBV-N). The antigenic stimulus that drives EBV-N PTLD is unknown, but is likely heterogeneous. A common feature of PTLD, regardless of EBV status, is an abnormal polytypic lymphoplasmacytic infiltrate. Immunglobulin-G4 (IgG4) syndrome is also characterized by a polytypic lymphoplasmacytic infiltrate with a predominance of IgG4-positive (IgG4-P) plasma cells. METHODS: We investigated the possibility of an association between EBV-N PTLD and IgG4 syndrome. Of 33 evaluated PTLD cases, 9 (27%) were EBV-N. EBV-N PTLD cases showed longer transplantation-to-diagnosis times than EBV-positive cases. RESULTS: A single patient had a preceding benign duodenal biopsy with focally prominent IgG4-P plasma cells; however, no clinical data supported IgG4 syndrome, precluding an association between IgG4 syndrome and subsequent EBV-N PTLD in this patient. CONCLUSION: As none of 29 evaluable cases of PTLD (including all 9 EBV-N cases) were associated with an increase in IgG4-P plasma cells, IgG4 syndrome does not appear to play a role in the etiology of EBV-N PTLD. The significance of these findings and the current understanding of the etiology of EBV-N PTLD are discussed.

Nocardiosis in solid-organ transplant recipients: spectrum of imaging findings.

Nocardiosis is an infrequent but severe infection that primarily affects the lung and thence is able to produce disseminated disease. Prompt diagnosis of pulmonary and disseminated nocardiosis is of utmost importance in solid-organ transplant recipients to reduce mortality. Knowledge of the different radiological manifestations in the appropriate clinical setting is key to successful management of these patients. The aim of this review is to describe the radiological features of nocardiosis in immunosuppressed patients, particularly in solid-organ transplant recipients.

Cryptosporidium enteritis in solid organ transplant recipients: multicenter retrospective evaluation of 10 cases reveals an association with elevated tacrolimus concentrations.

BACKGROUND: Cryptosporidial enteritis, a diarrheal infection of the small intestine caused by the apicomplexan protozoa Cryptosporidium, is infrequently recognized in transplant recipients from developed countries. METHODS: A retrospective review of all cases of cryptosporidiosis in solid organ transplant (SOT) recipients at 2 centers from January 2001 to October 2010 was performed and compared with transplant recipients with community-onset Clostridium difficile infection (CDI). A literature search was performed with regard to reported cases of cryptosporidiosis in SOT recipients. RESULTS: Eight renal, 1 liver, and 1 lung transplant recipient were diagnosed with cryptosporidiosis at median 46.0 months (interquartile range [IQR] 25.2-62.8) following SOT. Symptoms existed for a median 14 days (IQR 10.5-14.8) before diagnosis. For the 9 patients receiving tacrolimus (TAC), mean TAC levels increased from 6.3 ± 1.1 to 21.3 ± 9.2 ng/mL (P = 0.0007) and median serum creatinine increased temporarily from 1.3 (IQR 1.1-1.7) to 2.4 (IQR 2.0-4.6) mg/dL (P = 0.008). By comparison, 8 SOT recipients (6 kidney, 2 liver) hospitalized with community-onset CDI had a mean TAC level of 10.8 ± 2.8 ng/dL during disease compared with 9.2 ± 2.3 ng/mL at baseline (P = 0.07) and had no change in median creatinine. All patients recovered from Cryptosporidium enteritis after receiving various chemotherapeutic regimens. CONCLUSIONS: Cryptosporidiosis should be recognized as an important cause of diarrhea after SOT and is associated with elevated TAC levels and acute kidney injury. Increased TAC levels may reflect altered drug metabolism in the small intestine.

Pulmonary blood volume imaging with dual-energy computed tomography: spectrum of findings.

Dual-energy (DE) pulmonary blood volume (PBV) computed tomography (CT) has recently become available on clinical CT systems. The underlying physical principle of DECT is the fact that the photoelectric effect is strongly dependent on the CT energies resulting in different degrees of x-ray attenuation for different materials at different energy levels. DECT thus enables the characterization and quantification of iodine within tissues via imaging at different x-ray energies and analysis of attenuation differences. Technical approaches to DECT include dual-source scanners acquiring two scans with different energy levels simultaneously, and single-source CT scanners using sandwich detectors or rapid voltage switching. DE PBV CT enables the creation of iodine maps of the pulmonary parenchyma. Experience to date shows that these studies can provide additional physiological information in patients with acute or chronic pulmonary embolism beyond the pure morphological assessment a standard CT pulmonary angiography (CTPA) provides. It appears also to be promising for the evaluation of patients with obstructive airways disease. This article reviews the physics and technical aspects of DE PBV CT as well as the appearance of normal and abnormal lung tissue on these studies. Special consideration is given to pitfalls and artefacts.

Elevated stricture rate following the use of fully covered self-expandable metal biliary stents for biliary leaks following liver transplantation.

BACKGROUND: Biliary leaks and strictures are common complications after liver transplantation and can be managed surgically or endoscopically. Endoscopic management using fully covered self-expandable metal stents (FCSEMS) might provide some advantages over the commonly used plastic stents in the management of bile leaks after liver transplantation. METHODS: Between December 2006 and January 2009, 17 liver transplant recipients underwent placement of a FCSEMS for treatment of biliary leaks. RESULTS: FCSEMS were deployed at median of 18 days (range: 6 - 160) after liver transplantation and left in place for a median of 102 days (range: 35 - 427), with a median follow-up after FCSEMS removal of 407 days (range: 27 - 972). Long-term leak control was obtained in all but one patient. Complications included 6 clinically significant biliary strictures (35 %), which were treated with repeat stent placement, and two clinically insignificant strictures (12 %) which required no intervention. Additionally, three patients (18 %) had biliary ulcerations after stent removal, confirmed by choledochoscopy, and were managed conservatively. Two patients required repeat liver transplantation due to hepatic artery thrombosis, and one patient died from sepsis unrelated to FCSEMS stenting. CONCLUSIONS: FCSEMS treat biliary leaks effectively, but carry a relatively high stricture risk in patients who have received liver transplants. FCSEMS cannot be recommended for management of biliary leaks following liver transplantation at this point.

Colorectal and anal neoplasms following liver transplantation.

OBJECTIVE: Liver transplantation (LT) is the treatment of choice for end-stage liver disease. The required immunosuppression increases the risk for developing malignancies. Some viruses play a crucial role. Data on neoplasms of the colon, rectum and anus in LT are limited. METHOD: A retrospective evaluation of the incidence and clinical course of colorectal and anal malignancies and colonic polyps in a series of 467 consecutive LTs in 402 individuals between 1998 and 2001 was performed. Standard immunosuppression included Tacrolimus, Mycophenolic acid and steroids. RESULTS: During a median follow up of 5.2 years, three colon adenocarcinomas, one EBV associated cecal posttransplant lymphoproliferative tumour and two HPV associated anal tumours were identified. Pre-LT colonoscopy was performed in 161 patients (40%), and of 153 evaluable individuals, 53 (34.9%) had polyps. Colonoscopy was performed in 186 patients (46.3%) median 14.8 (range 0.2-77.8) months post-LT and 55 (29.3%) had polyps. Post-LT adenomatous polyps were detected in 47.3% of patients with pre-LT polyps vs 6.7% of patients without pre-LT polyps (P < 0.001). Patients with alcoholic liver disease had a significantly higher rate of adenoma formation (50.0% vs 11.1%, P < 0.001). No patient died from colorectal/anal malignancy. CONCLUSION: The incidence of metachronous and new polyp formation in our study is similar to people who are not immunocompromised, but subgroups are at increased risk. Viral-associated malignancies, including post-transplant lymphoproliferative disorders and anal cancer, are important entities in the LT population suggesting that complete screening of the colon, rectum and anus including pre-LT and post-LT colonoscopy should be utilized.

Group Milleri Streptococci in perianal infections.

BACKGROUND: Anal abscesses are commonly associated with fistulas-in-ano and are usually polymicrobial in nature, with gram-negative rods and anaerobes being the most prevalent isolates. Group Milleri Streptococci (GMS) comprise a heterogeneous group of cocci, which are capable of causing severe purulent infection with a high recurrence rate. METHOD: All anorectal infections caused by GMS, which were identified at our centre during a 4-year period were retrospectively analysed. The 18 patients with GMS-positive anorectal abscesses were matched with 36 GMS-negative anorectal abscesses to identify outcome characteristics of this clinical entity. RESULTS: During the study period, 358 patients underwent surgical treatment for anal infections; GMS were isolated in 46 individuals (13%) including 18 perianal abscesses, 11 pilonidal sinuses, eight fistulae in and nine miscellaneous infections. Seventy-two per cent of perianal GMS infections were polymicrobial with E. coli and Bacteroides fragilis being the predominant second bacteria. Nine patients (20%) developed recurrent abscesses and fistulae-in-ano and underwent additional surgical interventions with resolution at follow-up. Additional antibiotic treatment was administered in 10 patients with complex anal infections. Matched pair analysis revealed that GMS-positive perianal abscesses were more commonly polymicrobial, and that the recurrence rate was higher (55.6% GMS-positive and 22.2% GMS-negative patients, P = 0.017). CONCLUSIONS: Our data confirm the propensity of GMS to form deep and recurrent abscesses with a higher recurrence rate than non-GMS infections. First-line treatment includes surgical drainage, and antibiotic treatment may be useful in selected patients.

Vascular considerations for stapled haemorrhoidopexy.

OBJECTIVE: Modern haemorrhoidectomy techniques aim to interrupt arterial blood supply to the hypertrophied piles. The aim of this study was to investigate morphological and physiological alterations in the terminal branches of the superior rectal artery (SRA) in patients with haemorrhoidal disease treated by stapled haemorrhoidopexy (SH) using noninvasive transperineal ultrasound. METHOD: Thirty-seven consecutive patients (14 women, 23 men; median age 52, range 30-77 years) who underwent SH for treatment of grade III haemorrhoids were scanned by transperineal colour Doppler ultrasound at baseline, 4 weeks and 3 months postoperatively. Seventeen healthy volunteers served as the control group (nine women, eight men; median age 24, range 18-72 years). Calibre and arterial flow velocity (AFV) of the terminal branches of the SRA were measured. RESULTS: Baseline measurements significantly differed between patients and the control group (median calibre 2, range 0.9-3.6 mm, vs 1, range 0.6-1.2 mm, and median AFV 24, range 10-65 cm/s, vs 12, range 5-21 cm/s, P < 0.0001). Postoperative follow-up showed no significant alterations in the physiological parameters. Patients with a higher recurrence rate of haemorrhoidal disease had higher baseline AFV values. CONCLUSION: Stapled haemorrhoidopexy does not reduce arterial inflow in the feeding vessels of the anorectal vascular plexus. Preoperative ultrasound may serve as a tool for assessing vascularization status in haemorrhoidal disease and is useful in deciding whether patients should undergo SH or, for individuals with high AFV, whether conventional haemorrhoidectomy might be the better choice.

Successful management of postpneumonectomy Aspergillus pleural empyema by combined surgical and anti-fungal treatment with voriconazole and caspofungin.

Aspergillus pleural empyema is a rare but often fatal infection complicating thoracic surgery. Three men and one woman aged 23-47 years were diagnosed with Aspergillus pleural empyema after lung resection. Underlying diseases were lung cancer (n = 2), Hodgkin's disease (n = 1) and thoracic trauma (n = 1). The treatment protocol consisted of systemic anti-fungal treatment with caspofungin and voriconazole, intrapleural application of amphotericin B and surgical debridement with secondary closure of the leaking bronchial stump. Two patients with chronic Aspergillus pleural empyema had been pretreated with itraconazole and/or amphotericin B. Two patients were treated with a thoracostoma. Two patients had undergone pneumonectomy for previously diagnosed pulmonary aspergillosis. Caspofungin was given for 13-60 days, Voriconazole for up to 100 days. Surgical debridement was performed in all cases and in two cases the created thoracostoma was closed during a second surgical procedure. Aspergillus PCR using blood samples, bronchoalveolar lavage or aspiration fluid was used for monitoring. All four patients had complete clinical and microbiological remission. Our case series shows promising results and underscores the importance of a combined therapeutic approach for Aspergillus pleural empyema consisting of anti-fungal treatment and surgery. Voriconazole and caspofungin seem to be a suitable combination for this infection.

Pulmonary zygomycosis in solid organ transplant recipients in the current era.

Fifty-eight solid organ transplant recipients with zygomycosis were studied to assess the presentation, radiographic characteristics, risks for extra-pulmonary dissemination and mortality of pulmonary zygomycosis. Pulmonary zygomycosis was documented in 31 patients (53%) and developed a median of 5.5 months (interquartile range, 2-11 months) posttransplantation. In all, 74.2% (23/31) of the patients had zygomycosis limited to the lungs and 25.8% (8/31) had lung disease as part of disseminated zygomycosis; cutaneous/soft tissue (50%, 4/8) was the most common site of dissemination. Pulmonary disease presented most frequently as consolidation/mass lesions (29.0%), nodules (25.8%) and cavities (22.6%). Patients with disseminated disease were more likely to have Mycocladus corymbifer as the causative pathogen. The mortality rate at 90 days after the treatment was 45.2%. In summary, pulmonary zygomycosis is the most common manifestation in solid organ transplant recipients with zygomycosis, and disseminated disease often involves the cutaneous/soft tissue sites but not the brain.

Fatal cross infection by carbapenem-resistant Klebsiella in two liver transplant recipients.

Members of the family Enterobacteriaceae including Klebsiella have re-emerged as major pathogens in solid organ transplantation. The recent appearance and dissemination of carbapenemase-producing Enterobacteriaceae in Europe and the northeastern United States represents a major challenge to the treatment of enteric gram-negative bacterial infections in immunocompromised patients; however, few reports have detailed the outcomes of such infections. Here we report 2 cases of Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella infections in orthotopic liver transplant recipients, which were the index case and initial secondary case for an outbreak of KPC-producing Enterobacteriaceae in our institution. In both instances, the pathogens were initially misidentified as being carbapenem sensitive, the infections recurred after cessation of directed therapy, and the patients ultimately succumbed to their infections.

Pneumonia in solid organ recipients: spectrum of pathogens in 217 episodes.

BACKGROUND: Lower respiratory tract infection (LRTI) remains a leading cause of morbidity and mortality after solid organ transplantation (SOT). PATIENTS AND METHODS: We performed a retrospective analysis of 217 episodes of LRTI in 143 SOT patients from a single center. RESULTS: There were 94 men and 49 women (85% Caucasian) of median age of 51 (range 17-79) years, including 50 renal, 86 liver, 6 pancreas, and 1 lung recipient. Forty patients experienced multiple episodes of LRTI. Median APACHE II score was 17 (range 5-40), median temperature was 38 degrees C (range 35.3 degrees C-40.2 degrees C), and median white blood cell count was 12000 (range 100-106,000). Pneumonia developed at a median of 11 (range 2-191) days after the last surgical intervention. Of the 217 LRTIs, 163 were nosocomial infections (60 ventilator-associated). Overall crude mortality of 21% was increased in patients with multiple episodes of LRTI (25%) and after liver transplantation (33%). In 40 cases, treatment was initiated without identification of a specific pathogen. Overall, 202 microorganisms were found (41 mixed infections): Staphylococcus aureus (n = 32) of which 81% were MRSA; Escherichia coli (n = 9); Klebsiella spp (n = 7); Enterobacter spp (n = 11); Serratia spp (n = 12); Pseudomonas aeruginosa (n = 15); Stenotrophomonas maltophila (n = 15); Acinetobacter spp (n = 9); fungi (n = 18), and viruses (n = 17). CONCLUSION: LRTI remains one of the most common, dangerous infections in transplant recipients with higher mortality than in other populations. MRSA is a particular problem. As a significant number of SOT patients develop multiple episodes of LRTI, a thorough reevaluation of the current guidelines for the treatment of pneumonia is urgently needed.

The Innsbruck hand transplant program: update at 8 years after the first transplant.

We herein provide an update on two bilateral hand and one bilateral forearm transplants with emphasis on immunosuppression (IS), function, morphology, and graft vascular changes at 8 years and 2 years after bilateral hand and 5 years after bilateral forearm transplantation. Between March 2000 and May 2006, three patients underwent bilateral hand or forearm transplantation at our institution. Following induction therapy with antithymocyte globulin (ATG) (n = 2) or alemtuzumab (n = 1), tacrolimus, prednisolone +/- mycophenolate mofetil (MMF) were given for maintenance IS. Later, tacrolimus (n = 1) or MMF (n = 1) was replaced by sirolimus/everolimus for long-term IS. Clinical follow-ups with evaluation of hand function, skin biopsies, X-ray, ultrasound, angiography, computed tomography angiography, electrophysiological studies, and somatosensory evoked potentials were performed at regular intervals. Three, six, and three rejection episodes were successfully treated with bolused steroids, anti-CD25 or anti-CD52 antibodies. Subsequently, skin histology remained normal without any evidence of chronic rejection. Hand function continuously improved during the first 3 years and since then remained stable with minor improvements. Investigation of hand arteries revealed no signs of occlusion or stenosis. Motor and intrinsic hand muscle function continues to improve in all patients. Protective sensation was observed in all patients; however, discriminative sensation was only accomplished after hand but not forearm transplantation. No life-threatening adverse events occurred. Despite immunologic challenging postoperative courses, patients are now free of rejection with moderate levels of IS and good functional results. No signs indicating chronic rejection have been encountered.

Infectious complications in three double hand recipients: experience from a single center.

BACKGROUND: Composite tissue allograft (CTA) recipients require high level of immunosuppression and, therefore, are at significant risk to acquire opportunistic infections. PATIENTS AND METHODS: A review of all serious infectious complications in the 3 CTA recipients from the Innsbruck Medical University was performed. RESULTS: The most common infection was cytomegalovirus (CMV)-associated disease, which developed in all 3 individuals. The CMV match was CMV-positive donor/CMV-negative recipient in the first case and CMV-positive donor/CMV-positive recipient in the other 2. The first 2 patients developed complicated CMV infections despite ganciclovir (GCV) prophylaxis and required treatment with anti-CMV hyperimmunoglobulin, foscarnet, and cidofovir to control infection. The third patient had a mild course of CMV disease after withdrawel of prophylaxis, which was successfully treated with ValGCV. Whereas no major additional infections were observed in the first and third case, the second patient, who experienced multiple steroid-resistent rejections, experienced a variaty of additional infections, including 1 episode of Clostridium difficile-associated colitis (CDAC), a soft tissue infection with Alternaria alternata and an infection with human papilloma virus (HPV), which extensively involved both transplanted forearms. CDAC was successfully treated with metronidazole, Alternaria alternata with liposomal amphotericin B, and itraconazole and HPV lesions with topical cidofovir. CONCLUSION: Rare and difficult to treat infections must be expected in CTA recipients, in particular when donor-derived viruses are introduced in naïve recipients and when excessive immunosuppression is required. Meticulous infectious screening and prophylaxis are warranted in these high-risk patients.