RESUMO
BACKGROUND: Pulmonary mucormycosis (PM) is a life-threatening fungal infection with an increasing incidence among patients with acute leukemia. In some immunocompromised hosts, the reversed halo sign (RHS) has been described on the pulmonary computed tomographic (CT) scan of patients with mucormycosis. METHODS: This study reports a single-center experience with PM exclusively in patients with acute leukemia. Clinical records, laboratory results, and CT scans were retrospectively analyzed to evaluate the clinical usefulness of the RHS for the early identification and treatment of PM, with regard to outcomes in these patients. RESULTS: Between 2003 and 2012, 16 cases of proven PM were diagnosed among 752 consecutive patients receiving chemotherapy for acute myeloblastic or lymphoblastic leukemia. At the time PM was diagnosed, all patients but one were neutropenic. The study of sequential thoracic CT scans showed that during the first week of the disease, the RHS was observed in 15 of 16 patients (94%). Initially, other radiologic findings (multiple nodules and pleural effusion) were less frequent, but appeared later in the course of the disease (6% and 12% before vs 64% and 55% after the first week). After the diagnosis of PM, median overall survival was 25 weeks (range, 3-193 weeks), and 6 patients (38%) died before day 90. CONCLUSIONS: In the particular setting of neutropenic leukemia patients with pulmonary infection, the presence of the RHS on CT was a strong indicator of PM. It could allow the early initiation of appropriate therapy and thus improve the outcome.
Assuntos
Leucemia/complicações , Pneumopatias Fúngicas/diagnóstico , Pneumopatias Fúngicas/patologia , Pulmão/patologia , Mucormicose/diagnóstico , Mucormicose/patologia , Neutropenia/complicações , Adulto , Idoso , Feminino , Humanos , Leucemia/tratamento farmacológico , Pulmão/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
INTRODUCTION: In acute leukaemia (AL), the occurrence of pulmonary mucormycosis (PM), the incidence of which is increasing, as a result of chemotherapy induced marrow aplasia, remains a life threatening complication. METHODS: Analysis of clinical, biological and thoracic CT characteristics of patients with PM developing during the treatment of AL between 2000 and 2015. Day 0 (D0) was defined as the day with first CT evidence of PM. RESULTS: Among 1193 patients, 25 cases of PM were recorded during 2099 episodes of bone marrow aplasia. At time of diagnosis of PM, 24/25 patients had been neutropenic for a median of 12 days. None of the patients had diabetes mellitus. On initial CT (D0), the lesion was solitary in 20/25 cases and a reversed halo sign (RHS) was observed in 23/25 cases. From D1 to D7, D8 to D15 and after D15, RHS was seen in 100 %, 75 % and 27 % of cases, respectively. A tissue biopsy was positive in 17/18 cases. The detection of circulating Mucorales DNA in serum was positive in 23/24 patients and in 97/188 serum specimens between D-9 and D9. Bronchoalveolar lavage contributed to diagnosis in only 3/21 cases. The antifungal treatment was mainly based on liposomal amphotericin B combined with, or followed by, posaconazole. A pulmonary surgical resection was performed in 9/25 cases. At 3 months, 76 % of patients were alive and median overall survival was 14 months. CONCLUSION: In AL, early use of CT could improve the prognosis of PM. The presence of a RHS on CT suggests PM and is an indication for prompt antifungal treatment.
Assuntos
Leucemia Mieloide Aguda/complicações , Pneumopatias Fúngicas/complicações , Mucormicose/complicações , Antifúngicos/uso terapêutico , França , Humanos , Leucemia Mieloide Aguda/diagnóstico , Leucemia Mieloide Aguda/terapia , Pneumopatias Fúngicas/diagnóstico , Pneumopatias Fúngicas/terapia , Mucormicose/diagnóstico , Mucormicose/terapia , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
Invasive fungal infections (IFI) remain life-threatening complications in haematological patients. The aim of the study was to present the experience of a single centre in the surgical treatment of pulmonary IFI. Between 1992 and 2014, 50 haematological patients with IFI underwent pulmonary resection. In 27 cases it was an emergency procedure to avoid haemoptysis (if the lesion threatened pulmonary vessels). The remaining 23 patients underwent elective surgery before new chemotherapy or stem-cell transplantation. Among these patients (median age: 54 years; range: 5-70 years), 92% had acute leukaemia and 68% were on haematological first-line therapy (receiving induction or consolidation chemotherapies). Invasive pulmonary aspergillosis and pulmonary mucormycosis were diagnosed in 37 and 12 patients, respectively. One patient had IFI due to Trichoderma longibrachiatum. All of the patients received antifungal agents. In the month preceding IFI diagnosis, 94% of patients had been neutropenic. At the time of surgery, 30% of patients were still neutropenic and 54% required platelet transfusions. Lobectomy or segmentectomy were performed in 80% and 20% of cases, respectively. Mortality at 30 and 90 days post-surgery was 6% and 10%, respectively. After surgery, median overall survival was 21 months; median overall survival was similar between patients with emergency or elective surgery and between the types of IFI (invasive pulmonary aspergillosis or pulmonary mucormycosis). However, overall survival was far better in haematological first-line patients or in those achieving a haematological complete response than in other patients (p <0.001). In pulmonary IFI, lung resection could be an effective complement to medical treatment in selected haematological patients.
Assuntos
Doenças Hematológicas/complicações , Doenças Hematológicas/cirurgia , Infecções Fúngicas Invasivas/etiologia , Pneumopatias Fúngicas/etiologia , Procedimentos Cirúrgicos Pulmonares/efeitos adversos , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Serviço Hospitalar de Emergência , Feminino , Seguimentos , Doenças Hematológicas/terapia , Humanos , Infecções Fúngicas Invasivas/diagnóstico , Infecções Fúngicas Invasivas/mortalidade , Pneumopatias Fúngicas/diagnóstico , Pneumopatias Fúngicas/mortalidade , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados da Assistência ao Paciente , Pneumonectomia/efeitos adversos , Pneumonectomia/métodos , Modelos de Riscos Proporcionais , Procedimentos Cirúrgicos Pulmonares/métodos , Análise de Sobrevida , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
A 25-year-old woman developed "brain death" 48 h after acute methanol poisoning. After the elimination of methanol and the correction of metabolic disorders, organ donation was discussed. The lungs were transplanted into a 46-year-old woman suffering from cystic "emphysematous-like" lesions as a complication of lymphangioleiomyomatosis. The procedure was not complicated, and we have an uneventful follow-up of > 12 months. In addition to the lungs, the kidneys and the liver were also removed and transplanted with success.
Assuntos
Transplante de Pulmão , Metanol/intoxicação , Solventes/intoxicação , Doadores de Tecidos , Doença Aguda , Adulto , Feminino , Humanos , Neoplasias Pulmonares/cirurgia , Linfangioleiomiomatose/cirurgia , Pessoa de Meia-Idade , Transplante de ÓrgãosRESUMO
The aging process results in a significant attenuation of the reserve in organ function in normal man. For example, it is well established that cardiac output decreases with aging. Also the heart has decreased capacities to compensate for stress situations such as anesthesia and important surgery. In our study, we have evaluated the hemodynamic response after a blood volume expansion and dopamine administration in eighteen patients over 60 years of age. It should be of value in the assessment of cardiac performance in elderly patients, especially those with ASA physical classification III and before an anesthesia and surgery. Fluid administration resulted in an improvement of cardiac performance in fourteen patients (78%). Four patients (22%) had an increase of pulmonary capillary wedge pressure greater than 12 mmHg without amelioration of cardiac performance. Dopamine increased significantly cardiac index but only at a dose of 6 micrograms/kg/min and by increase of heart rate.
Assuntos
Hemodinâmica , Cuidados Pré-Operatórios , Procedimentos Cirúrgicos Operatórios , Idoso , Dopamina/uso terapêutico , Feminino , Hidratação , Hemodinâmica/efeitos dos fármacos , Humanos , Masculino , Pessoa de Meia-Idade , RiscoAssuntos
Linfócitos B/imunologia , Linfócitos B/metabolismo , Interleucina-10/metabolismo , Leucemia Linfocítica Crônica de Células B/tratamento farmacológico , Leucemia Linfocítica Crônica de Células B/etiologia , Leucemia Linfocítica Crônica de Células B/metabolismo , Polimorfismo Genético , Receptores de IgG/genética , Rituximab/uso terapêutico , Citotoxicidade Celular Dependente de Anticorpos , Linfócitos B/patologia , Feminino , Humanos , Masculino , Rituximab/administração & dosagem , Resultado do TratamentoRESUMO
BACKGROUND: Epothilones are 16-member ring macrolides with antimicrotubule activity that share a similar mechanism of action to the taxanes but have demonstrated potent antiproliferative activity in several different multidrug-resistant and paclitaxel-resistant tumor cell lines in vitro and in vivo. DESIGN: This review summarizes data from preclinical and phase I clinical studies of epothilone B (patupilone; EPO960) and epothilone D (KOS-862) and their second-generation (ixabepilone, BMS-310705, KOS-1584) and third-generation (ZK-EPO, ABJ-879) derivatives. Data were identified by searches of PubMed and the Proceedings of the American Society of Clinical Oncology annual meetings from 2000 to 2006. RESULTS: Epothilones demonstrate a linear dose-dependent pharmacokinetic profile, are well tolerated, and exhibit antitumor activity in a variety of tumor types in phase I studies of patients with cancer. Although similar in chemical structure, the epothilones demonstrate a striking difference in toxicity profile in phase I studies. Diarrhea is the dose-limiting toxicity (DLT) associated with patupilone, whereas neurotoxicity and neutropenia are the DLTs most commonly encountered with other epothilones. Consistent with preclinical data, partial responses were observed with patupilone and ixabepilone in patients with breast cancer previously treated with taxanes. CONCLUSION: The epothilones demonstrate promising antitumor activity in a broad spectrum of taxane-sensitive and -refractory tumors at doses and schedules associated with tolerable side-effects.