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A case of invasive aspergillosis
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A case of invasive aspergillosis

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  • 1. A case of invasive aspergillosis in a lung transplant patient Dr. Dino Sgarabotto Transplant ID Unit Padova General Hospital Italy
  • 2.
    • Cystic fibrosis
    • Pancreatic insufficiency
    • Insulin-dependent diabetes mellitus
    • Bilateral lung transplant (2008)
    • >> cyclosporine and steroids
    • Hypertension
    • Mild renal impairment
    AC, 35 years old
  • 3.
    • 2009 :
    • I nvasive aspergillosis involving:
    • brain, lung and mitral valve,
      • Treated with
      • Caspofungin and Voriconazole for 60 days
      • Voriconazole 200 mg bid for 16 months
      • No surgery
      • Sensitivity testing not done
    Clinical History [>> Urine culture grew Aspergillus sp ., so he received a longer treatment with caspofungin] September 2010 : Pneumocystis carinii pneumonia : ICU admission
  • 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. 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. Abdomen MRI
  • 7. Abdomen MRI
  • 8. Diagnosis Aspergillus prostatic abscess … plus….
    • PTLD
    • Renal cancer
    • Aspergilloma
  • 9. PET-CT scan
  • 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. Clinical case: March 2011… no fever, but… surgical enucleation
  • 12. Cultures: Surgical enucleation Hystology: aspergilloma
  • 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. 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.
    • We observed the development of microbiological resistance to Voriconazole and pharmacokinetic/clinical inefficacy of Caspofungin.
    • Voriconazole-resistant Aspergillus is a new problem
    • Efficacy of LAmB…
    • … but hard management because nefrotoxicity and concomitant use of Cyclosporine
    Conclusions (2)
  • 16.
    • In invasive aspergillosis: LAmB effectiveness only if combined to surgery?
    • Is there a genetic predisposition for invasive aspergillosis or are there other still unknown risk factors?
    • How can we manage antifungal secondary prophylaxis in this patient?
    • Secondary prophylaxis with iv Ambisome is not yet defined:
        • 3 mg/kg/daily 2 weeks a month?
        • 5 mk/Kg twice a week?
        • 10 mg/Kg/weekly? How long???
    Further questions

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