Disseminated adiaspiromycosis: case report of a liver transplant patient with human immunodeficiency infection, and literature review.

Disseminated adiaspiromycosis is a rare infection that is sometimes associated with immunocompromised situations. We report the case of a patient, infected with human immunodeficiency virus and receiving highly active antiretroviral therapy, who had a liver transplant for hepatocellular carcinoma. The patient presented skin and pulmonary lesions due to adiaspiromycosis during immunosuppressive therapy. A review of >60 cases in the literature shows that adiaspiromycosis is a rare infection and Emmonsia is a dimorphic fungus that is difficult to grow. It should be considered a possible diagnosis in case of fungal infection and pulmonary granulomatosis. We should be aware of emerging adiaspiromycosis in patients with risk factors of immunosuppression, particularly transplant recipients. In these patients in particular, liposomal amphotericin B therapy should be considered.

Risk of acute liver injury associated with the use of drugs: a multicentre population survey.

BACKGROUND: Acute liver injury of uncertain aetiology is often drug related and quantitative information about the associated risk is scarce. AIM: To estimate the risk of acute liver injury associated with the use of drugs. METHODS: In a population survey study, 126 cases of acute liver injury were prospectively assembled from January 1993 to December 1999, in patients over 15 years of age, in 12 hospitals in Barcelona (Spain). We estimated the relative risk for each drug as the ratio between the incidence of acute liver injury among the exposed population to the drug and the incidence of acute liver injury among those not exposed to it. Drug consumption data were used to estimate the exposed population. RESULTS: Isoniazid, pyrazinamide, rifampicin, amoxicillin with clavulanic acid, erythromicin, chlorpromazine, nimesulide, and ticlopidine presented the highest risk (point relative risk > 25). Amoxicillin, metoclopramide, captopril and enalapril, furosemide, hydrochlorothiazide, fluoxetine, paroxetine, diazepam, alprazolam, lorazepam, metamizole, low-dose acetylsalicylic acid and salbutamol showed the lowest risk (point relative risk < 5). CONCLUSIONS: This study provides a risk estimation of serious liver disease for various drugs that will be useful in its diagnosis and management, and when comparing with the drug therapeutic benefit in each indication. Some observed associations would be worth specific studies.

The impact of donor age on liver transplantation: influence of donor age on early liver function and on subsequent patient and graft survival.

BACKGROUND: The urgent need to increase the organ donor pool has led to the expansion of criteria for donor selection. The aim of this study was to analyze the influence of donor age on early graft function, subsequent graft loss, and mortality after liver transplantation (LT). METHODS: Data on LT were evaluated retrospectively in a population-based cohort of 400 LTs in 348 patients. Of these, 21 (5%) were from donors >70 years old. Pretransplantation donor and recipient characteristics and the evolution of recipients were analyzed. The influence of donor age as a risk factor was assessed using univariate and multivariate analyses. RESULTS: Actuarial graft survival was 89% at 1 month after LT, 81% after 6 months, and 59% after 60 months. Multivariate analysis demonstrated that only donor age (>70 years old) was associated with a higher risk of long-term graft loss (relative risk [RR]=1.4, 95% confidence interval [CI]=1-1.9; P=0.03) and mortality (RR=1.7, 95% CI=1.2-2.3; P=0.01). Graft survival of septuagenarian livers was 80% at 1 month after LT, 56% after 6 months, and 25% after 54 months. Actuarial survival analysis (Kaplan-Meier curves) also demonstrated worse evolution in recipients of livers from old donors (log-rank test, P<0.001). CONCLUSIONS: Advanced donor age is associated with lower graft and recipient survival.

Marrow aplasia during high dose mebendazole treatment.

A patient with chronic liver disease was treated with large doses of mebendazole for a hepatic hydatid cyst. Eighteen days after beginning treatment he developed marrow aplasia which reverted to normal after the drug was stopped. This is the marrow aplasia which reverted to normal after the drug was stopped. This is the sixth patient described as developing marrow aplasia when treated with large doses of mebendazole. We suggest that the aplasia is related to the dose of the drug, and that the patient's chronic liver disease was an important factor in its genesis. Patients treated with large doses of mebendazole should have their blood counts monitored during treatment.

Changes in liver function tests in patients with inflammatory bowel disease on enteral nutrition.

Morphologic and functional hepatic changes occur in inflammatory bowel disease (IBD). Patients with this disease often require the administration of artificial nutritional support. Liver function tests (LFT) derangement is a widely recognized side-effect of total parenteral nutrition (TPN). Therefore, the use of this modality of nutritional support may be an additional factor to cause hepatic damage in IBD patients. However whether or not the same occurs in patients receiving total enteral nutrition (TEN) is not well-established. The aim of the present study was to evaluate the effect of TEN upon LFT in patients with moderate to severe acute attacks of IBD, by means of a prospective, controlled, and nonrandomized design. Forty-nine patients were included; 29 (11 patients with ulcerative colitis and 18 with Crohn's disease) received TEN, and 20 (11 with ulcerative colitis and 9 with Crohn's disease) did not. Both groups were homogeneous regarding age, sex, disease activity index, nutritional status, and length of the study (24.8 +/- 1.3 vs 23.9 +/- 16.8 days). In all cases, weekly measurements of serum alkaline phosphatase, GOT, and GPT were performed. There were no significant differences in LFT at the beginning of the study between groups. The percentage of patients showing derangement of some LFT during the study did not differ between both groups: six of 29 (20.6%) in TEN group vs three of 20 (15%) in control group. Six out of the nine patients (in both groups) who developed LFT derangement had one or more causes, other than TEN for explaining hepatic dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of total enteral tube feeding on the vitamin status of malnourished patients with inflammatory bowel disease.

Eight malnourished patients (5 men and 3 women, mean age 26.5 +/- 0.4 years) suffering from Inflammatory Bowel Disease were prospectively included at admission to study the effect on protein-energy and vitamin status of a specially designed enterally tube fed formula diet. Eighty nine healthy individuals (36 men and 53 women, mean age 34 +/- 2 years) were used as controls. All but one patient were on steroids. The mean caloric supply was 58.2 +/- 2.4 kcal/kg/day with a mean nitrogen content of 0.37 +/- 0.02 gN/kg/day. The mean Total Enteral Nutrition period lasted 20.8 +/- 2.3 days (range 12 to 28 days). Fat- and water-soluble vitamins were studied at admission and after the nutritional period. Likewise both the protein-energy nutritional status and the activity of the disease were evaluated. At admission, plasma levels of folate, biotin, beta-carotene and vitamins A, C and E were significantly lower in patients than in controls. Tocopherol/cholesterol ratio, and vitamin B1, B2, B6, and B12 status were normal. At the end, plasma values of folate, biotin and vitamin C remained unchanged. However, the protein-energy nutritional status and the activity of the disease significantly improved. At admission, 4 out of 8 patients were at risk of developing hypovitaminosis for vitamins A, C, biotin, beta-carotene, and folate. At the end, a similar percentage remained at risk for these vitamins except for vitamin A. The content of some vitamins in the best designed formula diets does not meet the needs for patients with Inflammatory Bowel Disease.

Caroli's disease versus polycystic hepatic disease. Differential diagnosis with Tc-99m DISIDA scintigraphy.

Four patients with multiple hepatic cysts were studied: two were diagnosed with Caroli's disease (CD) and two with polycystic hepatic disease (PHD). In CD, hepatic scintigraphy with Tc-99m DISIDA showed areas of focally increased radiotracer accumulation that persisted more than 120 minutes, whereas in PHD, areas of focally decreased radiotracer accumulation were observed with normal liver washout and biliary excretion. When multiple hepatic cysts are shown by abdominal echography or CT scan, hepatic scintigraphy with Tc-99m DISIDA should be performed. This examination is safe and noninvasive, and permits differential diagnosis between CD and PHD.

[Analysis of 500 liver transplantations at Bellvitge Hospital, Spain]. / Análisis de 500 trasplantes hepáticos en el Hospital de Bellvitge.

BACKGROUND: We present the experience of the liver transplantation program at the Hospital of Bellvitge with 500 transplantations performed during 15 years, to describe changes in liver transplantation observed throughout the time and to analyze the long term results. PATIENTS AND METHOD: Five groups each one including 100 consecutive transplantations are studied. RESULTS: The main indications were hepatocellular carcinoma (23%), alcoholic cirrhosis (22.8%), and post-hepatitis C cirrhosis (18.8%). Sixty-five retransplantations were performed in 59 patients (13%), being the more frequent indications arterial thrombosis (13 patients) and primary nonfunction of graft (10 patients). In 10 patients a hepatorenal transplantation was performed. In group I, the most frequent donor cause of death was cranial traumatism (80%), while in group V it was the vascular pathology (52%). There were other significative differences between these groups of patients (I vs V): patients with stage 2 or 3 from UNOS status (45 vs 19%), blood use (29.6 [26] vs 4.6 [5.3] PRBC), ICU stay (13 [13] vs 7.4 [11] days), hospital stay (40 [52] vs 23.7 [17] days), rejection rate (46 vs 20%) and primary graft nonfunction (9 vs 3%). However, the infection rates (48 vs 54.5%) and biliary tract complications (26 vs 20%) have not shown statistically significant differences. Actuarial one and 5-year survival are 83 and 70% respectively. CONCLUSIONS: An important and progressive improvement of liver transplantation results has been observed. However, de novo tumours, hepatitis C virus recurrence and chronic rejection can limit long term results.

[Ectopic ascites secondary to the implantation of a LeVeen shunt]. / Ascitis ectópica secundaria a la implantación de un shunt de LeVeen.

Insertion of a peritoneovenous shunt is an effective method of treatment of refractory ascites although not free of complications. The incidence of them varies between 20-50%, being obstruction, infection and disseminated intravascular coagulation the more frequent. We report a case of a patient that presented with ectopic ascites in cellular subcutaneous tissue one year after the placement of the shunt. This complication was due to an increase of ascites. Treated with paracentesis the ascites decreased and the ectopic ascites resolved.

[Spontaneous rupture of the abdominal wall in cirrhotic patients with ascites]. / Rotura espontánea de la pared abdominal en enfermos cirróticos con ascitis.

The abdominal wall hernia is a common finding in cirrhotic patients. Spontaneous disruption of the abdominal wall through these herniae is an uncommon complication, is associated with a high mortality and should be considered a gastroenterologic emergency. It occurs through a skin ulceration over the hernia in the 70% of all cases. Intravascular expansion plus long antibiotic prophylaxis with anti-staphylococcal agents are the mainstays of medical therapy. The definitive treatment must be surgical. Each case must be evaluated individually to determine the optimal surgical management, not necessarily on an emergent basis. We report three new cases surviving this complication.

[The value of ADA in peritoneal tuberculosis]. / Valor del ADA en la tuberculosis peritoneal.

The aim of this study was to confirm that ascitic fluid determination of adenosine deaminase activity (ADA) is useful for the diagnosis of tuberculous peritonitis. 109 patients with ascites have been studied; 4 had tuberculous peritonitis and 105 nontuberculous ascites. The mean value of ascitic fluid AQDA was 0.587 +/- 0.2 uKat/l in tuberculous peritonitis and 0.11 +/- 0.1 uKat/l in nontuberculous ascites (p less than 0.001). An ADA value upper than 0.40 uKat/l has a sensitivity of 100% and a specificity of 99% for diagnosing tuberculous peritonitis. Ascitic fluid determination of ADA is simple, cheap and has a good diagnostic accuracy. In countries with high incidence of tuberculosis, measurement of ADA in ascitic fluid should be used as screening test for tuberculosis.

[Infectious gastroenteritis in relapses of inflammatory bowel disease. Therapeutic implications]. / Gastroenteritis infecciosa en los brotes de enfermedad inflamatoria intestinal. Implicaciones terapéuticas.

The incidence and clinical importance of infectious gastroenteritis was studied in 67 consecutive relapses of inflammatory bowel disease (IBD). A stool culture was done in every case before starting treatment. Stool culture was positive in 6 relapses (8.9%): Four were exacerbations of ulcerative colitis and two of Crohn's disease (8.8% in ulcerative colitis vs 9% in Crohn's disease; NS). The microorganisms isolated were Campylobacter jejuni in three cases, Salmonella enteritidis in two and Staphylococcus aureus in one case. There were not clinical differences between patients with positive and negative stool culture. Treated with antibiotics, stool cultures became negative in all of them but only in three the disease was controlled. The other three had to be treated with corticosteroids to achieve remission. We conclude that stool culture should be practised in all relapses of IBD and in case of positivity, antibiotic therapy should be started. With this approach the use of corticosteroids can be avoided in some patients.

Complications of thoracentesis in cirrhotic patients with pleural effusion.

OBJECTIVE: To study the complications of thoracentesis, either diagnostic or therapeutic, in cirrhotic patients with pleural effusion. EXPERIMENTAL DESIGN: A cohort prospective study. A diagnostic thoracentesis was performed at admission or when spontaneous bacterial empyema was suspected; a therapeutic thoracentesis was conducted in patients with dyspnea that did not improve with medical treatment. A chest radiography and a careful clinical follow up were performed in all patients within 24 hours after the procedure. We studied the risk factors for developing pneumothorax and the actuarial probability of pneumothorax after consecutive therapeutic thoracentesis. PATIENTS: All cirrhotic patients admitted with pleural effusion over a 4-year period. The study included 69 patients. RESULTS: During the study period, we performed 245 thoracentesis, 150 diagnostic and 95 therapeutic ones. The most severe complication was pneumothorax in 10 cases (4%), after 2 out of 150 (1.3%) diagnostic thoracentesis and after 8 out of 95 (8.4%) therapeutic thoracentesis (RR, 95% CI 6.8, 1.41-32.77, p < 0.01). The actuarial risk of pneumothorax after the first, second and fourth therapeutic thoracentesis was 7.7%, 25.3% and 34.7%, respectively. CONCLUSIONS: Diagnostic thoracentesis in cirrhotic patients is associated to a low morbidity. Therapeutic thoracentesis is a risk factor for pneumothorax and the risk increases after consecutive thoracentesis. A chest radiograph is not justified after a diagnostic thoracentesis, but should be done after a therapeutic thoracentesis.

[Diagnosis and treatment of esophageal ulcers in patients seropositive for the human immunodeficiency virus (HIV-positive)]. / Diagnóstico y tratamiento de las úlceras esofágicas en los pacientes seropositivos para el virus de la inmunodeficiencia humana (VIH-positivo).

Esophageal ulcers are often found in patients with human immunodeficiency virus infection. We have retrospectively reviewed the upper endoscopies performed in these patients during the last four years. 149 examinations were realized in 73 patients. Fourteen patients with esophageal ulcers were diagnosed. A severe immunological impairment was present in all patients (CD4 24.4 +/- 31.1 cells/ul). Symptoms were non-specific, with prevailing dysphagia and odynophagia. The etiological diagnosis was reached by histological studies and cultures in 5 cases (36%), three due to Herpes virus type I, one due to Cytomegalovirus and another one to Mycobacterium tuberculosis. Patients with multiple ulcers or small ones were successfully treated with antiviral drugs, even when the etiological studies were negative. Corticosteroids were useful in single and large ulcers in which diagnostic tests were negative.

Influence of donor post-reperfusion changes on graft evolution after liver transplant.

INTRODUCTION: The increase in indications for liver transplantation has meant that waiting lists are growing ever longer. For this reason, broadening the donor pool is a priority for most groups. OBJECTIVE: The objective of this study was to analyze the predictive value of post-reperfusion biopsy in the evolution of graft function after liver transplantation. PATIENTS: One hundred and forty-eight liver biopsies, obtained after graft reperfusion, were analyzed. Eight pathological variables and thirty-seven clinical variables of the donors were recorded. Risk factors for presenting primary graft non-function or dysfunction were studied with logistic regression models. Factors associated to the long-term graft failure were studied using Cox analysis and actuarial survival curves. RESULTS: Microvesicular steatosis greater than 50% was the only risk factor associated to graft dysfunction in the multivariate logistic regression model. Microvesicular steatosis greater than 30%, severe hepatocyte necrosis and presence of abundant neutrophilic leukocytes were risk factors associated to graft failure in the univariate study. Only steatosis remained as an independent risk factor in the multivariate study. These grafts also presented poorer long-term survival. Abundant polymorphonuclear infiltrate was associated to a higher frequency of biliary complications. CONCLUSIONS: Microvesicular steatosis implies a better evolution than macrovesicular steatosis. Neutrophilic infiltrate and hepatocellular necrosis lead to poorer initial graft function and reduced long-term survival.

[Domino or sequential liver transplantation. Is it a feasible technique?]. / El trasplante hepático dominó o secuencial, es una técnica factible?

BACKGROUND: In domino liver transplantation (LT), the explanted liver of a patient with familial amyloidotic polyneuropathy (FAP) is donated to another patient. PATIENTS AND METHOD: Between February 1999 and March 2001 we performed 131 LT with 121 cadaveric donors in our unit. Ten domino LTs were performed. RESULTS: Patients with FAP were younger (37 years) than recipients of the second LT (64 years). The evolution of patients undergoing transplantation for FAP was excellent and all are currently alive and without complications. Among recipients of the second LT, one patient died in the postoperative period. A further two patients died from tumoral recurrence and hepatitis C virus recurrence 18 months and 9 months after transplantation, respectively. The remaining patients have shown no symptoms of FAP during the follow-up. CONCLUSION: The results of this study show that domino LT is technically feasible. The technique increases the number of grafts without apparent risk either to the recipient with FAP or to the recipient of the latter's explanted liver.

[Is surgery for portal hypertension a contraindication for liver transplantation?]. / Representa la cirugía de la hipertensión portal una contraindicación al trasplante hepático?

INTRODUCTION: Orthotopic liver transplantation (OLT) is the only curative treatment for hepatic cirrhosis and is the most effective in the control of portal hypertension. The aim of this study was to analyze whether greater morbi-mortality is observed in patients undergoing liver transplantation with previous surgery for portal hypertension with respect to patients not having undergone this surgery. MATERIALS AND METHODS: Different variables were analyzed in 2 groups of transplanted patients: one of 18 patients who had previously undergone surgery for portal hypertension and another group of 54 patients without this previous surgery. RESULTS: The following factors were studied: mean operative time and length of anahepatic phase, intraoperative consumption of concentrates of erythrocytes, fresh frozen plasma, units of platelets and cryoprecipitates, days of mechanical ventilation, stay in the ICU and total postoperative stay. No significant differences were observed (p < 0.05) in any of these factors or in survival. DISCUSSION: On analysis of the difficulty of surgical technique, postoperative evolution and survival and based on the variables described it may be concluded that previous surgery for portal hypertension does not only not contraindicate posterior liver transplantation, but rather may be useful in patients with an adequate hepative reserve presenting variceal hemorrhage since posterior transplantation does not present a worsened prognosis.

[Resection as elective treatment of hilar cholangiocarcinoma (Klatskin tumor)]. / La resección como tratamiento de elección del colangiocarcinoma hiliar (tumor de Klatskin).

A retrospective analysis of our experience in the treatment of hiliary cholangiocarcinoma or Klatskin tumor was performed with the aim of evaluating the morbi-mortality and prognosis of its treatment to thereby determine the usefulness of the different therapeutic options. From 1989 to 1997, 51 patients diagnosed with hiliary cholangiocarcinoma were treated in our hospital. Surgery was indicated in 16 with curative aims (group I) while palliative treatment with percutaneous biliary drainage was indicated in 35 (group II). Biliary resection was carried out in 8 patients being associated with hepatic resection in 4 (group IA) and in 8 patients undergoing liver transplantation (group IB). Clinico-epidemiologic data and hospital stay were similar in all the groups. The frequency of complications was similar in groups I and II although the frequency of cholangitis (49%) in group II was noticeable. The percentage of readmissions was also greater in group II (12 vs 46%, respectively; p = 0.03) with prosthesis obstruction being the most frequent cause. Accumulated survival at 1, 2, and 3 years in group I was 84, 64 and 48% with a median survival of 33 months, while in group II the median survival was of 6 months with no patient surviving more than 2 years (p = 0.0001). When groups IA and IB were compared, greater frequency of complications in groups IA (100 vs 37%; p = 0.002), similar frequency of readmissions (87 vs 75%; p = NS), median survival greater in group IB (12.5 months vs 48 months) and significantly higher actuarial survival in group IB (48% in 2 years vs 83% to 2 years; p = 0.02) was observed. In conclusion, surgery is the treatment of choice in hiliary cholangiocarcinoma whenever possible, given the greater survival without a significant increase in morbimortality. Likewise, we consider that liver transplantation is a useful option in the treatment of patients with cholangiocarcinoma type IV of Bismuth.

Usefulness of reagent strips for checking cure in spontaneous bacterial peritonitis after short-course treatment.

BACKGROUND: The usefulness of reagent strips to check cure of spontaneous bacterial peritonitis have not been evaluated to date. AIM: To assess the usefulness of ascitic fluid analysis by means of reagent strips to check cure after a 5-day antibiotic course. METHODS: We prospectively included all cirrhotic patients diagnosed with spontaneous bacterial peritonitis. On day 5, conventional and reagent strip ascitic fluid analyses were performed. RESULTS: Fifty-three episodes of spontaneous bacterial peritonitis in 51 cirrhotic patients were included. Five patients died before the fifth day and in two patients, the control paracentesis yielded no ascitic fluid. In nine out of 46 cases (19.6%), spontaneous bacterial peritonitis had not resolved by day 5. In 32 out of 33 cases in which the ascitic fluid polymorphonuclear count was <250/microL at day five, the reagent strips was negative. The negative predictive value of the reagent strip at fifth day was 97% and the LR- 0.13. CONCLUSIONS: Almost 20% of episodes of spontaneous bacterial peritonitis do not resolve with a short-course of antibiotic treatment. In view of the high negative predictive value and low likelihood ratio for a negative test, reagent strips analysis may be an alternative to conventional cytology if a 5-day antibiotic therapy is planned.