Invasive aspergillosis in patients with cirrhosis, a case report and review of the last 10 years.

BACKGROUND: Untreated invasive aspergillosis (IA) is lethal, yet diagnosis is often delayed. Recognising the risk factors can lead to earlier diagnosis. We present a case of an invasive pulmonary aspergillosis in a patient with cirrhosis, who had been treated with corticosteroids for 2.5 weeks for alcoholic hepatitis. He was successfully treated with liposomal amphotericin B and caspofungin (first in combination, then caspofungin monotherapy). PURPOSE: To evaluate the role of aspergillosis in cirrhosis. METHODS: A literature search on aspergillosis in cirrhosis and liver failure patients was conducted in PubMed/Medline (2002-dec 2012), according to pre-set selection criteria. RESULTS: 20 out of 330 articles were retrieved, representing 43 patients with cirrhosis and/or liver failure who had an aspergillosis infection. Most Aspergillus (A.) infections were due to A. fumigatus and the lungs were the most frequent organ involved (42/43). 58% of the patients used steroids and mortality was 53.5%. The most frequent used antifungal was caspofungin. DISCUSSION: Diagnosis of IA is difficult and there might be a delay in diagnosis since cirrhosis is not recognised as one of the classical risk factors. Mortality was 53.5%, but this is lower than in previous decades. Since voriconazole is hepatotoxic, treatment with caspofungin and/or amphotericin is preferable. CONCLUSION: Early recognition of aspergillosis in a cirrhosis/liver failure patient is crucial and should prompt direct treatment.

Cost-effectiveness of adjuvant systemic therapy in low-risk breast cancer patients with nodal isolated tumor cells or micrometastases.

BACKGROUND: The cost-effectiveness of adjuvant systemic therapy in patients with low-risk breast cancer and nodal isolated tumor cells or micrometastases is unknown. PATIENTS AND METHODS: A cost-effectiveness analysis of adjuvant systemic therapy was carried out using the costs per 1% event prevented after 5 years of follow-up as incremental cost-effectiveness ratio (ICER). Secondary objective was to establish when adjuvant systemic therapy becomes cost saving. Patients included in the MIRROR study with isolated tumor cells or micrometastases who had a complete 5-year follow-up and who either did or did not receive systemic therapy were eligible. Sensitivity analyses were carried out. RESULTS: In the no adjuvant therapy cohort (N = 366), 24.9% of patients had an event within 5 years versus 16.8% of patients in the adjuvant therapy cohort (N = 483) (P < 0.01). The ICER was €363 per 1% event prevented. Beyond 18 years after diagnosis, the extrapolated mean cumulative costs per patient in the no adjuvant therapy cohort exceeded those of the adjuvant therapy cohort. CONCLUSIONS: In this population of breast cancer patients with isolated tumor cells or micrometastases, €36 300 had to be invested to prevent one event in 5 years of follow-up. Adjuvant systemic therapy was cost saving beyond 18 years after diagnosis.

Extensive acronecrosis as a manifestation of mixed cryoglobulinaemia: a case report.

Cryoglobulinaemia is a systemic disorder characterized by circulating antibodies that precipitate in the cold and resolve on rewarming. Three different types have been described, distinct in the class of immunoglobulins and their clonality. The clinical expression varies from purpura and arthralgia to progressive renal failure and even acronecrosis (1-3). Associated conditions are lymphoproliferative disorders, auto-immune diseases and chronic infections, but several cases occur in the absence of identifyable other disease states. The present communication reports on a case of mixed cryoglobulinaemia. Of particular interest are the rapidly progressive clinical evolution to acronecrosis of the four limbs, necessitating amputation, the presence of spurious leucocytosis and the absence of other systemic symptoms.