Managing a Mycotic Thoracoabdominal Aneurysm: The Importance of Molecular Diagnostics.

Pneumococcal mycotic aneurysms are rare and associated with significant mortality and morbidity. Early intravenous antibiotic therapy and surgical intervention is the mainstay of treatment. Pneumococci frequently autolyze in blood cultures, making microbiological diagnosis challenging. We present the case of a man in his mid 70s with multiple thoracoabdominal mycotic aneurysms. Surgery was performed to a threatening saccular aortic arch aneurysm. Samples were sent for microbiological analysis and all were culture negative. The samples were then referred for bacterial 16S ribosomal RNA sequencing, which revealed evidence of infection with Streptococcus pneumoniae.

Profiling inflammation and tissue injury markers in perfusate and bronchoalveolar lavage fluid during human ex vivo lung perfusion.

Objectives: Availability of donor lungs suitable for transplant falls short of current demand and contributes to waiting list mortality. Ex vivo lung perfusion (EVLP) offers the opportunity to objectively assess and recondition organs unsuitable for immediate transplant. Identifying robust biomarkers that can stratify donor lungs during EVLP to use or non-use or for specific interventions could further improve its clinical impact. Methods: In this pilot study, 16 consecutive donor lungs unsuitable for immediate transplant were assessed by EVLP. Key inflammatory mediators and tissue injury markers were measured in serial perfusate samples collected hourly and in bronchoalveolar lavage fluid (BALF) collected before and after EVLP. Levels were compared between donor lungs that met criteria for transplant and those that did not. Results: Seven of the 16 donor lungs (44%) improved during EVLP and were transplanted with uniformly good outcomes. Tissue and vascular injury markers lactate dehydrogenase, HMGB-1 and Syndecan-1 were significantly lower in perfusate from transplanted lungs. A model combining IL-1ß and IL-8 concentrations in perfusate could predict final EVLP outcome after 2 h assessment. In addition, perfusate IL-1ß concentrations showed an inverse correlation to recipient oxygenation 24 h post-transplant. Conclusions: This study confirms the feasibility of using inflammation and tissue injury markers in perfusate and BALF to identify donor lungs most likely to improve for successful transplant during clinical EVLP. These results support examining this issue in a larger study.

Observational study of lung transplant recipients surviving 20 years.

BACKGROUND: Lung transplant recipients have reduced long-term survival compared with other solid organ recipients. There is a lack of published data on the characteristics of very long term survivors. METHODS: We describe the demographics, clinical history and post-procedure function of all lung transplant recipients who have survived greater than 20 years at our centre. RESULTS: At the time of analysis there were 21 (16.4%) of 128 patients who survived over 20 years. The mean age at transplantation was 31.8 ± 9.9 years. Five of 21 had undergone single-lung, eight double-lung and eight heart-lung transplant procedures. At the last evaluation, mean percentage predicted FEV1 in recipients of single and double lung were 51.3% and 57.9% respectively. By 20 years, 19 (90.5%) patients had developed bronchiolitis obliterans syndrome (BOS) with three (14%) BOS 1, six (29%) BOS 2 and 10 (48%) BOS 3 and two (9.5%) free from BOS. The median time to onset of BOS was 9.7 years (range 1.6-17.9). Of eight patients (38%) who required renal replacement, four (19%) had successfully undergone renal transplantation and four (19%) were on haemodialysis. Only one patient (5%) had symptomatic osteoporosis. Nineteen patients (90%) were treated for hypertension. Five patients (24%) had diabetes, all with an underlying diagnosis of cystic fibrosis and four of them developing diabetes post operatively. CONCLUSIONS: In our experience, 20-year survivors of lung transplantation had a delayed onset of BOS and morbidities due to immunosuppression that can be appropriately managed leading to long-term survival.

Invasive biopsy is effective and useful after lung transplant.

BACKGROUND: Transbronchial biopsy (TBB) is widely used after lung transplant but may not be diagnostic. Our group has used invasive approaches, open lung biopsy (OLB) or video-assisted thoracoscopy (VAT), to establish a definitive diagnosis in unexplained clinical deterioration. We sought to demonstrate the risks and benefits of this approach. METHODS: A retrospective review was made of the case notes of the patients undergoing OLB or VAT during a 12-year period from August 1996. RESULTS: During a 12-year period in 442 recipients, there were 51 invasive biopsies in 45 patients (6 had 2 procedures), of which 41 (80%) were OLB and 10 (20%) were VAT. Time of biopsy ranged from 7 days to 11 years after transplant. Thirty-seven (73%) took place in the first year, including 12 (24%) within the first 30 days. Nine patients died within 30 days of biopsy; 7 of them were already ventilated. Overall, biopsy provided a new unsuspected diagnosis in 37% of patients and confirmed the diagnostic suspicion in 47%. In only 16% of patients did it fail to provide a result that was clinically useful. The results of 29 (57%) biopsies led to a change in treatment. Sixty-three percent of new diagnoses and 71% where clinical suspicion was confirmed resulted in a treatment change. In all but 2 cases, a change was made to medication. CONCLUSIONS: In this large series of invasive biopsies, there was a high rate of useful results, with a frequent change in treatment. Invasive biopsies are a safe intervention in ambulatory patients.

Late Streptococcus bovis infection of knee arthroplasty and its association with carcinoma of the colon: a case report.

Streptococcus bovis is a very rare cause of infection of joint arthroplasty. Infections with S. bovis have been reported to be associated with various gastrointestinal conditions. We present a case of total knee arthroplasty infected with S. bovis 40 months after a successful knee replacement. The diagnosis was established on joint fluid as well as blood cultures. Early diagnosis, arthroscopic wash out and appropriate antibiotics helped salvage the prosthesis. Early colonoscopy revealed carcinoma of the sigmoid colon that was surgically resected.