Gastric Mucormycosis in a Liver and Kidney Transplant Recipient: Case Report and Concise Review of Literature.

Mucormycosis is an uncommonly encountered fungal infection in solid organ transplantation. The infection is severe and often results in a fatal outcome. The most common presentations are rhino-sino-orbital and pulmonary disease. We describe a rare case of gastric mucormycosis in a patient with a combined liver-kidney transplant affected by glycogen storage disease type Ia. A 42-year-old female patient presented with gastric pain and melena 26 days after transplantation. Evaluation with upper endoscopy showed two bleeding gastric ulcers. Histological examination of gastric specimens revealed fungal hyphae with evidence of Mucormycetes at subsequent molecular analysis. Immunosuppressive therapy was reduced and antifungal therapy consisting of liposomal amphotericin B and posaconazole was promptly introduced. Gastrointestinal side effects of posaconazole and acute T-cell rejection of renal graft complicated management of the case. A prolonged course of daily injections of amphotericin B together with a slight increase of immunosuppression favored successful treatment of mucormycosis as well as of graft rejection. At 2-year follow-up, the woman was found to have maintained normal renal and liver function. We conclude that judicious personalization of antimicrobial and antirejection therapy should be considered to resolve every life-threatening case of mucormycosis in solid organ transplantation.

Vacuum-Assisted Closure Therapy in Patients Undergoing Liver Transplantation With Necessity to Maintain Open Abdomen.

BACKGROUND: Negative-pressure wound therapy (NPWT) has been recognized as a valid method of temporary abdominal closure. The role of open abdomen (OA) in the management of abdominal sepsis has been a controversial issue. Recent experimental and clinical studies have indicated that vacuum-assisted closure (VAC) is associated with superior outcomes in the treatment of OA conditions, but sufficient proof of efficacy and effectiveness is lacking. METHODS: We enrolled in this observational study all patients who had undergone liver transplantation (LT) for all causes between 2007 and 2014 in whom we needed to use VAC therapy, describing the pathology that led to the complication, length of hospitalization, graft survival, microbial identifications, and causes of death. RESULTS: We enrolled 11 patients-6 men (55%) and 5 women (45%), from 41.92 to 64.96 years old (mean, 57.62 ± 6.56 years) -who went to LT for different pathologies. The mean hospital stay was 56.72 ± 36.40 days (range, 8-133 days). Graft survival was 35.65 ± 31.61 months (range, 1.51-89.19 months). Six of 11 patients died (55%) of different causes; in particular, 4 patients died 1 to 3 months after the procedures that led to the condition of OA for septic shock and subsequent multi-organ failure. CONCLUSIONS: Complications related to the use of NPWT, such as painful management and bleeding, are rare and mild when the device is used properly. Although studies are needed to verify the real cost/benefit ratio in this application of VAC therapy, we consider it a useful means to treat the OA condition.

Incidental Intra-Hepatic Cholangiocarcinoma and Hepatocholangiocarcinoma in Liver Transplantation: A Single-Center Experience.

BACKGROUND: Cholangiocarcinoma (CCA) is an aggressive malignancy of the biliary tract that is a challenging issue for the medical community, with increasing incidence. Risk factors for CCA are similar to those known for hepatocellular carcinoma (HCC), such as cirrhosis, chronic hepatitis B and C, obesity, diabetes, and alcohol. We describe the outcome and the management of patients who underwent liver transplantation (LT) with an incidental diagnosis of intrahepatic (iCCA) or hepatocholangiocarcinoma (CHC). METHODS: From 2000 to May 2015, 655 LT were performed LT at the Liver Transplant Center in Modena, Italy. We retrospectively reviewed the pathological data of the explanted livers, finding 5 cases of iCCA or CHC. The pathological examination of the explanted livers showed 1 case of iCCA; 1 case of multifocal HCC associated with a nodule of iCCA; 2 cases of CHC associated with nodules of HCC; and 1 case of CHC associated with iCCA. Mean disease-free survival (DFS) was 15.49 months (1.55-42.04) and mean overall survival (OS) was 24.76 months (3.91-75.49). All patients died of recurrent tumor progression. RESULTS: iCCA incidental finding after LT affects patient outcomes, massively causing OS and DFS reduction. We stress the necessity of a more accurate selection of the candidates whenever an augmented risk of iCCA or CHC is present. CONCLUSIONS: Further investigations are required to better understand the role of LT in these patients and to define the best management for them once they have been transplanted and the histological examination reveals the presence of iCCA or CHC.