Association of topical amphotericin B lipid complex treatment to standard therapy for rhinomaxillary mucormycosis after liver transplantation: a case report.

Solid organ transplantation is becoming increasingly more common in the treatment of end-stage organ failure. The advent of newer immunosuppressive protocols and refined surgical techniques has allowed therapy to become standard care. Infection is a major and frequently life-threatening complication after transplantation and the incidence of opportunistic fungal infections in organ transplant recipients ranges from 2%-50% depending on the type of organ transplanted. We present a case of rhinomaxillary form of mucormycosis infection after liver transplantation. The succession of multiple risk factors in a torpid postoperative period was a key factor in the development of this disease. Multidisciplinary management with an early diagnosis, aggressive surgery, and intravenous and topical antifungal therapy care were definitive for the eradication of infection. The goal of the present report was to show efficacious management including the association of topical treatment with amphotericin B complex lipid to standard therapy and the absence of side effects.

[Role of daptomycin in the empirical and directed therapy of infections caused by Gram-positive bacteria in the critically ill patient]. / Papel de daptomicina en el tratamiento empírico y dirigido de infecciones por cocos grampositivos del paciente crítico.

Infections caused by Gram-positive bacteria are a serious problem and is associated with high mortality. Among them, we should highlight those caused by methicillin-resistant Staphylococcus aureus (MRSA). Primary bacteremia, catheter-related bloodstream infections and constitute the main presentations. Vancomycin has traditionally been the treatment of choice for these infections, but its activity is not satisfactory especially in cases of MRSA with minimum inhibitory concentration (MIC) > 1 mg/L. Daptomycin is a lipopeptide antibiotic active against Gram-positive bacteria including MRSA and glycopeptide-resistant Enterococcus spp.It is worth mentioning that daptomycin is rapidly bactericidal against methicillin-sensitive S. aureus, more potent than vancomycin and at least as active as isoxazole penicillins. This article discusses the role of this antibiotic in the empirical treatment of infections and directed by Gram-positive bacteria affecting critically ill patients.

Renal transplantation in Mapuche people.

Previous studies have demonstrated higher concentrations of some histocompatibility antigens in Mapuche people compared with non-Mapuche Chileans in the renal transplantation program. With the aim of evaluating whether those antigenic differences might induce differences in the outcomes of renal transplantation among patients belonging to that ethnic group, we reviewed HLA studies and at least 6 months follow-up of all patients with a first kidney transplant between 1980 and 2006. The 248 patients had a mean age of 37.6 years, 40% were females, and 48% had living related donors. The mean kidney follow-up was 90 months and patient follow-up was 106 months. Thirty-nine patients (16%) were classified as Mapuche, according to their surnames, including 16 women with overall mean age of 34.5 years, and 14 had been transplanted from a living related donor. Mapuche patients received organs with better HLA matching expressed as number of identities (3.4 +/- 0.1 versus 2.8 +/- 0.1 among non-Mapuche; P < .05), and the proportion receiving organs with > or = 3 compatibilities was significantly higher (Mapuche 38% versus non-Mapuche 22%; P < .05). Kaplan-Meier survival curves showed nonsignificant differences in kidney survival: 86% at 5 years and 68% at 10 years in Mapuche; and 83% and 65%, respectively, for non-Mapuche. Patient survival rates were 97% at 5 years and 86% at 10 years in the Mapuche group versus 91% and 79%, respectively, in the non-Mapuche group; both results were not significantly different. Our results showed similar outcomes of kidney and patient survivals among Mapuche people even when they received organs with better HLA matches.

No gender-associated differences of cyclosporine pharmacokinetics in stable renal transplant patients treated with diltiazem.

Cytochrome-P450 enzymes metabolize cyclosporine both in the liver and in the intestinal wall. Diltiazem, by competitive inhibition of these enzymes, may increase the absorption and the bioavailability of cyclosporine. Some evidence points to a higher activity of some specific enzymes in women, such as CYP3A, that may influence differences in cyclosporine pharmacokinetics. We examined possible gender-associated differences in pharmacokinetic profiles of cyclosporine in 19 stable renal transplant recipients cotreated with diltiazem. Ten women and nine men, chronically using diltiazem associated with cyclosporine, azathioprine, and prednisone were randomly assigned to an 8-week period of continued controlled treatment with diltiazem (10 patients) or a wash-out period discontinuing diltiazem (nine patients). At the end of this period, the time-concentration curves of cyclosporine in the first 4 hours were performed after a single dose of cyclosporine. Thereafter, a cross-over between groups was performed, and time-concentration curves repeated. A specific RIA was used to measure cyclosporine concentrations. Comparisons between male and female patients in doses of cyclosporine and other pharmacokinetics parameters (C(0), C(2), AUC(0-4)), with or without diltiazem, did not show any difference related to gender. The association of diltiazem allowed a similar degree of reduction in Neoral dosage in male and female patients (21%). No changes in serum creatinine, blood urea nitrogen, potassium, uric acid, or blood pressure, or other adverse event were observed during the study. In these groups of patients, gender was not an important factor to be considered when diltiazem is added to cyclosporine therapy.

Human leukocyte antigens in indigenous (mapuche) people in a regional renal transplantation program in chile.

An active regional transplantation program established in the southern region of Chile has allowed the incorporation of ethnic minorities particularly Mapuche living in this geographic area in the development of a histocompatibility database. To identify possible differences in the human leukocyte (HLA) antigen distribution in Chilean Mapuche compared with non-Mapuche, we reviewed 442 HLA tissue-typing studies. Seventy-eight of 309 recipients (25%) and 18 of 133 donors (13%) were Mapuche. Among recipients, Mapuche people showed a significantly higher frequency of the HLA antigens, A28, B16, DR4, and DR8, and a lower one for A19, B15, and DR1 (P < .05) compared with non-Mapuche individuals. A particularly higher frequency of the haplotype A28, -B16, -DR4 was also evidenced in Mapuche. Besides, these recipients showed a higher frequency of the allele -DR4 when compared with Mapuche donors. A greater frequency of some histocompatibility antigens in patients with chronic renal disease might be attributed to allelic concentration due to a high index of endogamy, but a possible association with the development of progressive renal disease cannot be ignored, especially when a higher prevalence of DR4 was observed among Mapuche recipients.

Correlation Between C2 and AUC(0-4) in Renal Transplant Patients Treated With Diltiazem.

BACKGROUND: The area-under-the-curve (AUC) of cyclosporine (CsA) reflects exposure to the drug, but this monitoring strategy is time-consuming and not cost-effective. Recently, it has been suggested that the concentration at 2 hours after dosing (C2) shows the best correlation with AUC. The C2 has been replacing the trough measurement (C0) to monitor CsA therapy, but in patients receiving diltiazem there is not much information about this issue. We investigated the correlations between C2 and C0 with absorption AUC over the first 4 hours (AUC(0-4)) in renal stable transplant patients receiving CsA therapy with or without diltiazem. PATIENTS AND METHODS: Ten patients (five men) of ages 23 to 68 years and 6 to 84 months after transplantation, were randomly assigned to an 8-week initial period of either diltiazem washout or controlled treatment with diltiazem. Time-concentration curves of cyclosporine were performed at the end of this period using a specific RIA measurement of blood samples. Thereafter, a crossover of the groups was performed and after another 8 weeks, a second curve was obtained. Drugs that change the pharmacokinetics of cyclosporine or diltiazem were not allowed. RESULTS: The cyclosporine daily dose was lower with diltiazem (173 +/- 4 mg vs 213 +/- 4 mg, P = .002), but despite a dose reduction of only 19% +/- 1.5%, there was a trend to a larger AUC/dose (28 +/- 5 ng x h/mL x mg vs 17 +/- 2 ng x h/mL x mg, P = .1) and a trend to an increased C2 when treatment included diltiazem (1035 +/- 156 ng/mL vs 652 +/- 126 ng/mL, P = NS). Moreover, we confirmed that C2 showed the best correlation with AUC(0-4), (r = 0.7, P = .04), a correlation that improved with diltiazem (r = 0.9, P < .002). CONCLUSION: C2 is the point that correlates best with AUC(0-4) with or without diltiazem. C2 in the presence of diltiazem was associated with a stronger, more significant correlation with AUC(0-4).

Valsartan-induced hematocrit changes in renal transplant patients.

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor type 1 blockers (ARB) are frequently prescribed for renal transplant patients. The main reasons for their use are that their antihypertensive and antifibrogenic effects may prevent chronic renal allograft dysfunction, potentially improving transplant survival. Furthermore, ACE and ARB have been used to reduce the hematocrit in patients with posttransplant erythrocytosis. We evaluated the effects of the ARB valsartan on the evolution of hematocrit in stable renal transplant patients treated with cyclosporine (CsA), azathioprine (Aza), and prednisone. PATIENTS AND METHODS: Twenty-six stable renal transplant patients treated with valsartan 80 mg/d orally were followed for 6 months. Evaluations were performed prior to as well as at 3 and 6 months following the initiation of valsartan. RESULTS: The hematocrit levels decreased significantly at 3 months (46.1 +/- 7.3 vs 39.9 +/- 5.8 ; P < .0001) in patients with a normal hematocrit, namely a level over 38%, with no further reduction at 6 months. In recipients with an hematocrit less than 38%, there was no significant reduction, either at 3 or 6 months follow-up. Valsartan was well tolerated without significant side effects. CONCLUSION: We postulate that inhibition of the proerythropoietic effects of angiotensin II and/or the reduction in hypoxia within the renal tubulointerstitium as well as the vasodilator effects on the efferent arterioles, represent possible mechanisms for the reduction and stabilization of the hematocrit in stable renal transplant patients.

Tétanos: importancia del diagnóstico clínico en un servicio de urgencias / Tetanus: importance of clinical diagnosis in an emergency service

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ARDS associated with boutonneuse fever.

The adult respiratory disease syndrome is associated with multiple disorders. At least one of the rickettsial diseases, RMSF, has been reported to be associated with noncardiogenic pulmonary edema. We report herein another rickettsial disease, boutonneuse fever, which is produced by Rickettsia conorii and is usually a mild disease, that in our patient was associated with ARDS.