Do Prior Driveline Infections Increase the Risk of Infection in Heart Transplant Patients Treated With Rabbit Antithymocyte Globulin Induction Therapy?

BACKGROUND: The use of mechanical circulatory support devices (MCSDs) has been increasing over the past several years. Driveline infections (DLIs) are one of the most common complications seen in these patients; reportedly, up to 50% of patients with MCSDs can develop this complication. It is believed that the removal of the driveline results in treatment of the localized infection area. MCSD patients are also known to develop circulating antibodies. These circulating antibodies have been associated with poor outcomes after heart transplantation. The use of rabbit antithymocyte globulin (ATG) as induction therapy reportedly decreases the development of circulating antibodies; it is now commonly used in sensitized patients undergoing heart transplantation. It is unknown whether ATG induction therapy immediate posttransplant will increase the risk of infection of those MCSD patients with DLIs. METHODS: Between 2003 and 2013, we evaluated 57 MCSD patients who subsequently underwent heart transplantation and received ATG induction therapy. Patients were divided into those with previous MCSD DLI and those without, and they were assessed for 1-year freedom from infection (specifically, sternal wound infections). One-year survival and freedom from treated rejection, both cellular and antibody mediated, were also assessed. RESULTS: MCSD patients with DLIs who received ATG induction did not have a lower freedom from any treated infection and from sternal wound infection posttransplant compared with those MCSD patients without DLIs and not treated with ATG induction. There were also no significant differences between the 2 groups in terms of 1-year posttransplant survival and freedom from treated rejection. CONCLUSIONS: The use of ATG induction in patients with prior DLIs did not seem to increase the risk for posttransplant infection (eg, sternal wound infection). ATG induction can therefore be safely used in this population.

Heart transplantation for Chagas cardiomyopathy in the United States.

Since an initial case in 2006, we noted multiple patients undergoing heart transplantation (HTx) for Chagas cardiomyopathy (CC) at our transplant program. The clinical characteristics, laboratory results and outcomes of patients with CC undergoing HTx in the United States have not been reported previously. In 2010, we implemented a systematic screening and management program for patients undergoing HTx for CC. Before HTx, all patients with idiopathic dilated cardiomyopathy who were born in a Chagas disease endemic country were screened for Trypanosoma cruzi (TC) infection with serology. After HTx, monitoring for TC reactivation was performed using clinical visits, echocardiography, endomyocardial biopsy and serial whole blood polymerase chain reaction (PCR) testing. Between June 2006 and January 2012, 11 patients underwent HTx for CC. One patient was empirically treated due to the presence of TC amastigotes in explanted cardiac tissue. Two patients experienced allograft dysfunction due to TC reactivation and three patients experienced subclinical reactivation (positive PCR results), which were treated. Chagas disease is a common cause of dilated cardiomyopathy in patients from endemic countries undergoing HTx at a transplant program in the United States. Reactivation is common after transplantation and can cause adverse outcomes.

Infections in patients with chronic adult T-cell leukemia/lymphoma: case report and review.

Adult T-cell leukemia/lymphoma (ATLL) is caused by the human T-cell lymphotropic virus type I (HTLV-I). ATLL is classified into the smoldering, chronic, lymphoma, and acute subtypes. We describe a North American woman with chronic ATLL who presented with pneumonia caused by Pneumocystis carinii, Cryptococcus neoformans, Mycoplasma pneumoniae, and Mycobacterium avium complex. Although opportunistic infections have been documented in patients with ATLL, there are few case reports detailing infectious complications in patients with chronic ATLL.

Utility of inhaled pentamidine prophylaxis in lung transplant recipients.

The incidence of Pneumocystis carinii pneumonia (PCP) has been shown to be high posttransplantation in the absence of prophylaxis. For this reason, lung transplant recipients routinely receive prophylaxis. We report on our results using aerosolized pentamidine prophylaxis in nine patients post-lung transplantation (eight single lung transplants, one double). The patients received monthly treatments of 300 mg of aerosolized pentamidine for a mean of 10.6 months (range, 4 to 21 months). Patients were routinely monitored with serial pulmonary function studies and bronchoscopy as clinically indicated. Two of the patients experienced bronchospasm in response to the therapy. None of the patients experienced any episodes of PCP during the period of inhaled pentamidine prophylaxis. Inhaled pentamidine is a safe and effective form of PCP prophylaxis and may be used instead of sulfamethoxazole-trimethoprim in patients who have a sulfa allergy or other untoward sulfa side effects.

Risk of acquisition of genital herpes simplex virus type 2 in sex partners of persons with genital herpes: a prospective couple study.

In a prospective study of factors associated with genital herpes simplex virus (HSV) type 2 transmission in couples in whom 1 partner had clinical genital HSV and the other did not, 11 (19%) of the 57 history-negative partners had HSV-2 antibody by Western blot at entry. In follow-up (mean, 16 months) of 29 HSV-2-seronegative partners, overall 4 (14%) seroconverted compared with 3 (23%) of 13 HSV-1- and -2-seronegative partners and 1 (6%) of 16 HSV-1-seropositive partners. Since all seroconverters were women, the risk of transmission may be higher in HSV-seronegative women. No significant differences were found between HSV-2-seronegative partners and seroconverters regarding duration of relationships, number of partner recurrences, intercourse frequency, or contraceptive method. However, 2 seroconverters were exposed to lesions without barrier contraception. This study suggests that infection is commonly asymptomatic and that although the overall risk of genital HSV transmission in couples is low (10%/year), the risk may be significantly increased in women and in seronegative individuals.

Early treatment with acyclovir for varicella pneumonia in otherwise healthy adults: retrospective controlled study and review.

The effect of early acyclovir therapy on the course of varicella pneumonia in previously healthy adults was assessed. Medical records from five university-affiliated medical centers were retrospectively reviewed; included were all immunocompetent adults with a clinical diagnosis of primary varicella, a chest radiograph consistent with varicella pneumonia, and an arterial blood gas measurement indicating significant hypoxia. Of the 38 patients who met the study criteria, 11 had had a course of intravenous acyclovir initiated within the first 36 hours of hospitalization; the mean time from admission to initiation of therapy in this early-treatment group was 9.6 hours. The group that received early acyclovir treatment had a lower mean temperature beginning on the fifth day of hospitalization (37.0 degrees C vs. 37.7 degrees C; P = .011) and a lower mean respiratory rate beginning on the sixth day of hospitalization (21 vs. 28 respirations per minute; P = .004). Early acyclovir therapy also resulted in a significant improvement in oxygenation beginning on the sixth day of hospitalization in patients with follow-up arterial blood gas measurements (P = .035). Thus, early institution of acyclovir therapy is associated with reduction in fever and tachypnea and improvement in oxygenation in otherwise healthy adults with varicella pneumonia.

New biphasic culture system for isolation of mycobacteria from blood of patients with acquired immune deficiency syndrome.

A new biphasic medium consisting of a 7H11 agar slant and brain heart infusion broth liquid phase has been used for the past 10 months at the University of California at Los Angeles for isolation of Mycobacterium avium complex from blood. In 12 patients whose blood cultures were grown on this medium, the median time for isolation of M. avium complex was 7 days (range 6 to 15 days) compared with 21 to 27 days on a fungal medium and 28 to 38 days on routine blood culture medium. The system has provided a reliable and rapid way to obtain morphology and rapid identification of colonies produced from blood samples of patients with acquired immune deficiency syndrome, who are at high risk for M. avium complex mycobacteremia.

Mycobacterium avium: a pathogen of patients with acquired immunodeficiency syndrome.

Mycobacterium avium complex has been isolated with increasing frequency from humans during the last few decades. Thirteen patients admitted to the UCLA Medical Center with the diagnosis of acquired immunodeficiency syndrome (AIDS), in addition to having Kaposi's sarcoma, Pneumocystis pneumonia, and other opportunistic infections, also had M. avium complex isolated from a variety of tissues and fluids submitted for culture. Of these patients, 10 had histologic and bacteriologic evidence of disseminated mycobacterial infection, and M. avium complex was isolated from the blood of 5. The organisms were isolated from routine bacteriologic and diphasic fungal blood culture bottles. Periodic cultures of sputum, urine, and other body fluids and tissues should be performed for mycobacterial infections in all such patients. Routine blood cultures should be kept for at least 8 weeks to check for the presence of acid-fast bacteria in general and for M. avium complex in particular from all patients with immune deficiencies.

Lack of significant person-to-person spread of swine influenza-like virus following fatal infection in an immunocompromised child.

In February 1982, a four-year-old Nevada girl with acute lymphoblastic leukemia in remission was hospitalized with fulminant pneumonia and died eight days later at a hospital in California. An influenza virus was the only pathogen detected, and was present in both antemortem and postmortem specimens. The virus was closely related antigenically to A/New Jersey/8/76 (H1N1) and had a genome very similar to a contemporary enzootic swine influenza virus. The patient had had no known contact with swine, and the source of infection could not be determined. Only five possible secondary cases could be detected by retrospective investigation of 62 contacts, and there was no evidence of spread to the general community. Swine influenza viruses circulate among pigs in the United States annually, and it is likely that sporadic transmissions to humans will continue to be detected. Nevertheless, person-to-person spread under these circumstances appears to be limited.

Disseminated Mycobacterium avium-intracellulare infection in homosexual men dying of acquired immunodeficiency.

Five homosexual men dying at UCLA Center for the Health Sciences, Los Angeles, with acquired immunodeficiency and Pneumocystis pneumonia, Kaposi's sarcoma, or cryptosporidiosis since May 1981 have all had mycobacteria of the Mycobacterium avium-intracellulare complex cultured from tissues taken just before death or at postmortem examination. Each man had histological evidence of disseminated mycobacterial infection. Acid-fast organisms were seen in macrophages in the lung, spleen, and lymph nodes in all cases and in a variety of additional organs in two cases. Other severe infections were always found at postmortem examination--cytomegalovirus, cryptosporidiosis, and Pneumocystis. Disseminated M avium-intracellulare infection has been so striking in homosexual males dying with acquired immunodeficiency at our institution that we believe a vigorous search for mycobacteria should be made in all such patients. Empiric therapy for mycobacterial infection may be justified in selected cases of immunodeficiency before a specific microbiological diagnosis.