A case of invasive aspergillosis

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A case of invasive aspergillosis

  1. 1. A case of invasive aspergillosis in a lung transplant patient Dr. Dino Sgarabotto Transplant ID Unit Padova General Hospital Italy
  2. 2. <ul><li>Cystic fibrosis </li></ul><ul><li>Pancreatic insufficiency </li></ul><ul><li>Insulin-dependent diabetes mellitus </li></ul><ul><li>Bilateral lung transplant (2008) </li></ul><ul><li>>> cyclosporine and steroids </li></ul><ul><li>Hypertension </li></ul><ul><li>Mild renal impairment </li></ul>AC, 35 years old
  3. 3. <ul><li>2009 : </li></ul><ul><li>I nvasive aspergillosis involving: </li></ul><ul><li> brain, lung and mitral valve, </li></ul><ul><ul><li>Treated with </li></ul></ul><ul><ul><li>Caspofungin and Voriconazole for 60 days </li></ul></ul><ul><ul><li>Voriconazole 200 mg bid for 16 months </li></ul></ul><ul><ul><li>No surgery </li></ul></ul><ul><ul><li>Sensitivity testing not done </li></ul></ul>Clinical History [>> Urine culture grew Aspergillus sp ., so he received a longer treatment with caspofungin] September 2010 : Pneumocystis carinii pneumonia : ICU admission
  4. 4. The patient suffered from fever and urine retention. Treated unsuccessfully with ciprofloxacin. Persistence of 39°C intermittent fever every 3 days: new hospitalization December 2010 Blood and urine culture: negative WBC: normal; anemia CRP: 128 mg/dL PSA: normal Creatinine: 132 mmol/L Chest X-Ray: negative
  5. 5. December 2010 Transrectal US: small prostatic abscess Cultures from post-prostatic massage fluid: Aspergillus spp . Abdomen US: 4.5 cm mass on the left upper kidney Chest CT scan, echocardiography and cerebral MRI : unremarkable.
  6. 6. Abdomen MRI
  7. 7. Abdomen MRI
  8. 8. Diagnosis Aspergillus prostatic abscess … plus…. <ul><li>PTLD </li></ul><ul><li>Renal cancer </li></ul><ul><li>Aspergilloma </li></ul>
  9. 9. PET-CT scan
  10. 10. The patient was restarted on voriconazole/caspofungin 3 weeks later fever unchanged, CRP 110 mg/dL and voriconazole trough level 3.2 ug/dL Patient treatment hystory Therapy was switched to Liposomal Amphotericin B 3mg/Kg/daily quick (1 day) disappearance of fever, CRP normalization, new culture of post-prostatic massage fluid: negative
  11. 11. Clinical case: March 2011… no fever, but… surgical enucleation
  12. 12. Cultures: Surgical enucleation Hystology: aspergilloma
  13. 13. Follow up: May-July 2011 US scan: no recrudescence No fever … but.. STOP LAmb 3 mg/kg/die LAmb 3 mg/kg/die
  14. 14. Lung transplant recipients are at high risk of invasive Aspergillosis. However, isolated urinary involvement of invasive aspergillosis is uncommon and its treatment is very controversial. Conclusions (1)
  15. 15. <ul><li>We observed the development of microbiological resistance to Voriconazole and pharmacokinetic/clinical inefficacy of Caspofungin. </li></ul><ul><li>Voriconazole-resistant Aspergillus is a new problem </li></ul><ul><li>Efficacy of LAmB… </li></ul><ul><li>… but hard management because nefrotoxicity and concomitant use of Cyclosporine </li></ul>Conclusions (2)
  16. 16. <ul><li>In invasive aspergillosis: LAmB effectiveness only if combined to surgery? </li></ul><ul><li>Is there a genetic predisposition for invasive aspergillosis or are there other still unknown risk factors? </li></ul><ul><li>How can we manage antifungal secondary prophylaxis in this patient? </li></ul><ul><li>Secondary prophylaxis with iv Ambisome is not yet defined: </li></ul><ul><ul><ul><li>3 mg/kg/daily 2 weeks a month? </li></ul></ul></ul><ul><ul><ul><li>5 mk/Kg twice a week? </li></ul></ul></ul><ul><ul><ul><li>10 mg/Kg/weekly? How long??? </li></ul></ul></ul>Further questions
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