Chronic laryngitis caused by Mycobacterium Kansasii in a traveler.

Chronic laryngitis commonly presents with dysphonia, and infectious causes include tuberculosis and endemic mycoses. We present a 58-year-old female with laryngitis for 5 years, fevers, chills, fatigue, malaise, myalgias, anterior neck pain, and night sweats after multicontinent exposure. Bronchoscopy cultures were negative. Bilateral microflap excision of vocal fold lesions demonstrated thickened epithelium and a deep vocal fold mass. Biopsy showed necrotizing granulomatous inflammation with acid-fast bacilli. Mycobacterium kansasii was identified. Treatment led to improvement in dysphonia, systemic symptoms, and vocal fold irritation. To our knowledge, this is the first case of isolated nontuberculous mycobacterial vocal fold infection. Laryngoscope, 129:2534-2536, 2019.

Selecting suitable solid organ transplant donors: Reducing the risk of donor-transmitted infections.

Selection of the appropriate donor is essential to a successful allograft recipient outcome for solid organ transplantation. Multiple infectious diseases have been transmitted from the donor to the recipient via transplantation. Donor-transmitted infections cause increased morbidity and mortality to the recipient. In recent years, a series of high-profile transmissions of infections have occurred in organ recipients prompting increased attention on the process of improving the selection of an appropriate donor that balances the shortage of needed allografts with an approach that mitigates the risk of donor-transmitted infection to the recipient. Important advances focused on improving donor screening diagnostics, using previously excluded high-risk donors, and individualizing the selection of allografts to recipients based on their prior infection history are serving to increase the donor pool and improve outcomes after transplant. This article serves to review the relevant literature surrounding this topic and to provide a suggested approach to the selection of an appropriate solid organ transplant donor.

Staphylococcus aureus bacteremia in solid organ transplant recipients: evidence for improved survival when compared with nontransplant patients.

BACKGROUND: Staphylococcus aureus bacteremia (SAB) is an important cause of morbidity and mortality. Herein, we describe the incidence, clinical characteristics, and outcomes of SAB after solid organ transplantation (SOT) and compare these features with non-SOT controls. METHODS: In a single-center retrospective study, blood cultures positive for S. aureus were obtained from January 1, 2000, to December 31, 2008. Chart review was performed on all SOT recipients with SAB. The social security death index was used to determine all-cause mortality. RESULTS: Seventy of 2959 patients with SAB were SOT recipients (26 lung, 19 liver, 18 kidney, and seven heart). The overall attack rate of SAB in SOT was 22.9/1000 transplant patients. Early-onset SAB (≤ 90 days) was more frequent in liver recipients (79%), when compared with kidney recipients (17%). All-cause 30-day and 1-year mortality rates were 6% and 28% in SOT, respectively. Pneumonia as a source was associated with an increased 30-day mortality (18% vs. 2%, P = 0.04). Comparing SOT versus non-SOT controls, methicillin resistance was more frequent (86% vs. 52%, P < 0.0001), and duration of bacteremia was longer (mean 3.8 vs. 1.6 days, P < 0.01). SOT status was independently associated with lower risk of 30-day mortality (risk ratio [RR]: 0.37, P = 0.02). CONCLUSIONS: In our cohort of SOT recipients, SAB was less common than previously reported and surprisingly had lower 30-day mortality, when compared with non-SOT. In SOT recipients, pneumonia as a source of SAB in SOT is associated with an increased 30-day mortality.

Utility of leflunomide in the treatment of complex cytomegalovirus syndromes.

BACKGROUND: Cytomegalovirus (CMV) viremia that is resistant or refractory to the standard antiviral therapy still constitutes a major threat to high-risk transplant recipients. In addition, multiple CMV recurrences may lead to neutropenia because of repeated courses of therapy with ganciclovir derivatives. Leflunomide, a drug for rheumatoid arthritis, has been reported to have anti-CMV activity. This study reports on its use in 17 transplant recipients with complex CMV syndromes who had failed or were intolerant to other therapies. METHODS: Single-center, retrospective study. Clinical data were extracted from the electronic medical record. CMV DNA viral loads were performed by quantitative hybrid capture assay. RESULTS: Leflunomide was initiated after a median of three episodes of CMV viremia, with a mean peak viral load of 245,826 copies/mL. Initial clearance of CMV viremia was observed in 14 of 17 patients (82%), and 9 of 17 (53%) patients achieved a long-term suppression of CMV recurrences. Higher peak viral load and higher viral load at the start of leflunomide therapy were associated with failure to suppress viremia. The duration of leflunomide therapy ranged from 1 to 24 months (median 3.5 months, interquartile range 2.6-7 months), and the mean time to an undetectable CMV-DNA was 1.9 months. Adverse effects included diarrhea (35%), anemia (18%), and increased liver function tests (12%). CONCLUSIONS: Leflunomide, alone or in combination, has potential utility in treatment of complex CMV syndromes and in long-term suppression of viremia. The optimal duration of therapy and the balance of risks and benefits are not yet known.

Can donors with prior hepatitis be safely used for heart transplantation?

BACKGROUND: Heart transplantation represents a significant life-saving and increased quality-of-life intervention for patients with refractory cardiac failure. Successful transplantation requires continuous immunosuppression to avoid immune rejection. Unfortunately, persistent viral infections in donors may be transmitted to recipients in the process of heart transplantation. With the severe shortage of available organs and significant waiting list mortality there is a rationale for considering use of organs from donors with evidence of prior hepatitis B and/or hepatitis C infection. METHODS: Published literature articles were searched using Medline, PaperChase and further review of references in relevant articles on issues related to hepatitis B and hepatitis C and heart transplantation. RESULTS: Donor and recipient testing for hepatitis B and hepatitis C is important for relative risk assessment. Nucleic acid testing for hepatitis B DNA and hepatitis C RNA represent emerging technologies, which may add valuable information to traditional serologic testing. CONCLUSIONS: Heart transplant recipient risk may be modified by vaccination against hepatitis B before transplantation. There is currently no available vaccine for hepatitis C. Recently described effective treatments for hepatitis B and hepatitis C provide further rationale for reconsideration of using hearts from donors with evidence of hepatitis B and/or hepatitis C infection.

The impact of hypogammaglobulinemia on infection outcome in patients undergoing ventricular assist device implantation.

BACKGROUND: Infection is a major comorbidity after ventricular assist device (VAD) placement. Defects in cellular immunity have been reported after VAD placement. However, to our knowledge, quantitative immunoglobulin G (IgG) level determination and the impact of hypogammaglobulinemia (HGG) on infections after VAD implantation have not been evaluated before. METHODS: A total of 76 patients (mean age, 53 years) underwent VAD implantation as a bridge to transplantation and had IgG levels determined as a baseline before transplantation. Patients were divided into 2 groups according to IgG level: Control Group (n = 56, IgG > or = 700 mg/dl) and HGG Group (n = 20, IgG < 700 mg/dl). Infection outcome during the VAD course and after transplantation was analyzed in relation to the IgG level. RESULTS: Baseline characteristics were similar in both groups. The incidence of bacteremia (14/20 [70%] vs 18/56 [32%], p = 0.0032) and major infection (19/20 [95%] vs 31/56 [56%], p = 0.0009) were significantly increased in the HGG Group compared with the Control Group. After transplantation, the episodes of rejection were similar in both groups and survival was similar. The HGG Group experienced more cytomegalovirus infections compared with the Control Group (9/20 [45%] vs 9/56 [16%], p = 0.009). CONCLUSIONS: VAD patients with HGG are at increased risk of infections. After transplantation, these patients also experience increased cytomegalovirus infections. A randomized preemptive IgG replacement trial may be warranted in the future to determine if this intervention will alleviate the risk of infection.

Donor or recipient hepatitis B seropositivity is associated with allograft vasculopathy.

BACKGROUND: Increasing interest has focused on possible viral triggers of cardiac allograft vasculopathy. Although much interest has centered on cytomegalovirus, it has recently been noted that donor hepatitis C seropositivity is associated with risk for accelerated vasculopathy. The current study hypothesized that hepatitis B (HBV) might be associated with accelerated vasculopathy. METHODS: Sixty-six patients who received heart transplants between September 1998 and July 2000 were analyzed by intravascular ultrasound within 6 weeks and again at 12 months after transplantation. These patients were divided into 2 groups: the HBV Group (n = 13) in which either the donor or recipient was seropositive for hepatitis B core antibody (HBcAb), and a Control Group (n = 53) in which neither donor nor recipient was positive for HBcAb. RESULTS: Baseline characteristics of the 2 groups were similar. The HBV Group had significant increase in the change in average intimal area (1.59 +/- 1.4 vs 0.46 +/- 0.4 mm2, p = 0.01) per mm length of the vessel compared with controls. Allograft vasculopathy at 1 year (defined as largest maximal intimal thickness increase of > or =0.50 mm) occurred in 46% of the HBV group compared with 24% of the control group (p = 0.05). When measured as an average maximal intimal thickness increase of >0.30 mm, allograft vasculopathy at 1 year occurred in 31% of the HBV Group compared with 5% of Controls (p = 0.01). CONCLUSIONS: These preliminary results suggest that HBV seropositivity in donor or recipient may be associated with an increased risk for cardiac allograft vasculopathy.

Fatal West Nile Virus infection after rituximab/fludarabine--induced remission for non-Hodgkin's lymphoma.

West Nile virus (WNV) infections are potentially life threatening in immunocompromised hosts. Currently, the best diagnostic test is serology. Reverse-transcriptase polymerase chain reaction (RT-PCR) testing has a role, but, because WNV is a cell-associated neurotropic virus, RT-PCR results are frequently negative even in cases of active infection. We present a case in which serology results were persistently negative because the patient was immunocompromised following lymphoma treatment. The role of humoral immunity in resolution of WNV is also discussed.

The impact of CytoGam on cardiac transplant recipients with moderate hypogammaglobulinemia: a randomized single-center study.

BACKGROUND: We have previously shown that the preemptive use of cytomegalovirus (CMV) immunoglobulin (Ig) replacement (CytoGam) decreases the incidence of opportunistic infections in cardiac transplant recipients with severe hypogammaglobulinemia. However, the impact of Ig replacement in moderately hypogammaglobulinemic patients is unknown. METHODS: Periodic monitoring of the IgG levels was done in 300 heart transplant recipients. Moderate hypogammaglobulinemia (IgG, 350-500 mg/dl) developed in 56 patients (18.6%). Thirty-three patients declined randomization but agreed to have their IgG levels monitored. Twenty-three patients were randomized to placebo (n = 10) or CytoGam (n = 13) at 105 +/- 63 days after transplantation. RESULTS: The baseline characteristics were similar. A significant reduction in CMV infection was noted in the CytoGam Group compared with the Placebo Group (15.4% [2/13] vs 60% [6/10], p = .039). Among patients who declined randomization, CMV infection developed in 13 (39.4%) of 33, and 6 (46.1%) of the 13 progressed to severe hypogammaglobulinemia. A trend for reduction in the average episodes of > or =grade 2 rejection during the 6-month period after randomization was noted in the CytoGam group (0.4 +/- 0.6 vs 1.4 +/- 1.3, p = 0.065). CONCLUSIONS: The preemptive use of CytoGam decreases the incidence of CMV infection in patients with moderate hypogammaglobulinemia. A larger randomized study is needed to substantiate these results.

Cell-mediated immune response to influenza vaccination in lung transplant recipients.

BACKGROUND: Lung transplant recipients are susceptible to complications from influenza infection. Antibody responses to influenza vaccination have been shown to be decreased in lung transplant recipients. Cellular immune mechanisms serve an important role in influenza clearance. The cellular immune response to influenza vaccination has not been studied in transplant populations. METHODS: Interleukin-2, interleukin-10, interferon-gamma, and granzyme B levels to the three viral antigens included in the 1999 to 2000 influenza vaccine were measured before and 4 weeks post-vaccination in 43 lung transplant recipients and 21 healthy adult controls. RESULTS: Interleukin-2, interleukin-10, interferon-gamma, and granzyme B levels did not increase from pre- to post-vaccination in the lung transplant group. Both pre- and post-cytokine levels were lower in the transplant group compared to the control group. Pre- and post-granzyme B levels did not differ significantly between the groups. The T-helper response in the control group varied with the different viral strains. A correlation between acute rejection episodes and the absence of both azathioprine and mycophenolate was found. CONCLUSIONS: Influenza vaccination does not stimulate a cell-mediated immune response in lung transplant recipients as judged by interleukin-2, interleukin-10, interferon-gamma, and granzyme B levels. Alternative prevention strategies may be needed.

A case of fatal West Nile virus meningoencephalitis associated with receipt of blood transfusions after open heart surgery.

First identified in the United States in 1999, West Nile virus caused approximately 3,500 infections in the late summer and fall of 2002. The virus is predominantly transmitted by mosquitoes, and the risk of infection through blood product transfusion is believed to be low. We present a case of West Nile virus encephalitis transmitted by red blood cell transfusion at the time of coronary artery bypass grafting that resulted in the patient's death. Individuals undergoing procedures with high blood product transfusion requirements, such as cardiac surgery or organ transplantation, may be at higher risk of this nosocomial infection during epidemics.

Predictive value and cost-effectiveness analysis of a rapid polymerase chain reaction for preoperative detection of nasal carriage of Staphylococcus aureus.

OBJECTIVE: To determine the accuracy and cost-effectiveness of a polymerase chain reaction (PCR) for detecting nasal carriage of Staphylococcus aureus directly from clinical specimens. CROSS-SECTIONAL STUDY: This occurred in a tertiary-care hospital in Cleveland, Ohio, and included 239 consecutive patients who were scheduled for a cardiothoracic surgical procedure. Conventional cultures and a PCR for S. aureus from nasal swabs were used as measurements. COST-EFFECTIVENESS ANALYSIS: Data sources were market prices and Bureau of Labor Statistics. The time horizon was the maximum period for availability of culture results (3 days). Interventions included universal mupirocin therapy without testing; initial therapy, with termination if PCR negative (treat-PCR); initial therapy, with termination if culture negative (treat-culture); treat PCR-positive carriers (PCR-guided treatment); and treat culture-positive carriers (culture-guided treatment). The perspective was institutional and costs and the length of time to treatment were outcome measures. RESULTS: Sixty-seven (28%) of the 239 swabs grew S. aureus. Rapid PCR was 97.0% sensitive and 97.1% specific for the detection of S. aureus. For populations with prevalences of nasal S. aureus carriage of up to 50%, the PCR assay had negative predictive values of greater than 97%. PCR-guided treatment had the lowest incremental cost-effectiveness ratio (1.93 dollars per additional day compared with the culture strategy). Among immediate treatment strategies, treat-PCR was most cost-effective. The universal therapy strategy cost 38.19 dollars more per additional day gained with carrier identification compared with the PCR strategy. CONCLUSION: Rapid real-time PCR is an accurate, rapid, and cost-effective method for identifying S. aureus carriers for preoperative intervention.