Disseminated nocardiosis: a rare infectious complication following non-heart-beating donor liver transplantation.

Nocardiosis is an infrequent disease that affects patients who display a cellular immunodeficiency, such as transplant recipients on immunosuppressive treatment, but uncommonly associated with high morbidity and mortality rates. Disseminated Nocardiosis affecting the central nervous system (CNS), abdomen, skin, and lungs has been described in bone marrow, lung, and kidney transplant recipients. However, to our knowledge, no cases involving all of these structures have been reported in liver transplant recipients. Herein, we have reported a case of CNS, pulmonary, and cutaneous nocardiosis in a liver transplant recipient who experienced hepatitis C virus-related cirrhosis and hepatocellular carcinoma and received the organ from a non-heart-beating donor. At posttransplantation month 7 the patient was admitted to the emergency department with poor general health status, fever, edema, and subcutaneous nodules in the legs. A computed tomography scan revealed multiple nodules disseminated through both lungs, abdomen, brain, and subcutaneous tissue. A needle biopsy was performed into one of the subcutaneous nodules. Cultures of the material tested positive for Nocardia farcinica. Thus, we started treatment with intravenous sulfamethoxazole-trimethoprim (SMZ-TMP), shifting after 1 month to oral therapy. Radiological examination performed after 2 weeks of treatment showed a 70% reduction in subcutaneous, pulmonary, and cerebral lesions. After 6 months of SMZ-TMP treatment, the patient remained free of the symptoms with involution of the subcutaneous nodules and significant radiological improvement. Among opportunistic infections appearing in liver transplant recipients, Nocardia species should have special consideration according to the success of early treatment and the bad prognosis in cases of delayed diagnosis.

Second case of neurocysticercosis in a patient with liver transplantation (first case in Spain): a case report.

BACKGROUND: Neurocysticercosis (NCC) is a disorder caused by the Taenia solium larva. It is the most common parasitosis of the central nervous system (CNS). Its distribution is universal, but it is endemic in many developing countries and in the third world. In Spain most patients come from countries where the condition is endemic. However, sporadic cases occur among the population of rural regions. NCC in transplant recipients is uncommon. One renal transplant recipient developed NCC but responded to treatment with praziquantel. Recently, it has been reported to complicate a liver transplantation. CASE REPORT: The patient was a 49-year-old Ecuatorian man who received a cadaveric donor liver graft in June 2001 due to acute liver failure induced by toadstool and was under treatment with FK506. In January 2006, the patient presented with a generalized onset of a tonic-clonic seizure for 1 minute without sphincter incontinence, headache, fever, or previous brain trauma. Neurological evaluation did not show evidence of organic brain dysfunction. The neuroimaging findings (brain) computed tomography scan, magnetic resonance imaging were compatible with NCC: many cystic lesions intra- and extraparenchymatous with a scolex visible in three of them. Serology for cysticercosis in plasma was initially indeterminate but positive afterward. The patient was treated with anticonvulsivants (valproic acid) and albendazole. Systemic steroids were added in order to reduce the edema produced upon death of the cyst. Treatment lasted 3 weeks and it was completed without complications or neurological symptoms. Liver function was not affected. One year later the patient remained asymptomatic. CONCLUSION: NCC is a condition that must be included in the differential diagnosis of patients with CNS involvement and cystic lesions on neuroimaging investigations in transplant recipients, especially patients originating from or traveling to endemic areas. First-line therapy for active cysts includes antiparasitic drugs (albendazole or praziquantel) as well as steroids and anticonvulsivants. In our patient, this therapy was effective.

Liver transplantation for hepatocellular carcinoma: our experience from 1986.

UNLABELLED: Currently liver transplantation is the treatment of choice for early hepatocellular carcinoma and end-stage liver disease. We analyzed our experience to identify factors that could be used to select patients who will benefit from liver transplantation. PATIENTS AND METHODS: From April 1986 to December 2001, 71 (8.7%) of 816 LT performed in our institution, were for patients with hepatocellular carcinoma. In 25 patients the tumor was observed incidental by (35.2%). All patients had liver cirrhosis, most due to hepatitis C related (35) or alcoholic (14) diseases. Before liver transplantation, chemoembolization was performed in 18 patients (25.4%). RESULTS: Bilateral involvement was present in seven patients. Eight patients showed macroscopic vascular invasion, and eight others showed satellite nodules. Most patients were stage TNM II (29) and IVa (16). Overall 1-, 3-, and 5-year survival were 79.3%, 61%, and 50.3% with recurrence-free survivals of 74.6%, 57.5%, and 49%, respectively. With a mean follow-up of 42 months, 12 patients (19%) developed recurrence and 29 patients died (only 11 due to recurrence). Stage TNM IVa, macroscopic vascular invasion, and the presence of satellite nodules significantly affected overall survival and recurrence-free survival rates and histologic differentiation and bilateral involvement only recurrence-free survival. Patients with solitary tumors less than 5 cm or no more than three nodules smaller than 3 cm showed better recurrence-free survival and lower recurrence rates. DISCUSSION: In our experience, liver transplantation proffers good recurrence-free survival and low recurrence rates among patients with limited tumor extension. The most important prognostic factor was macroscopic vascular invasion.

Results of 22 years of experience in radical surgical treatment of hepatic hydatid cysts.

BACKGROUND/AIMS: As there is still no effective parasiticide, treatment of hydatid cysts continues to be surgical. The possibility of treatment by PAIR. (puncture-aspiration-instillation-reaspiration) or laparoscopy has intensified the debate on the need for radical surgery. This study aims to show that radical surgical resection of the hepatic hydatid cyst is a safe and very effective technique, based on our results after 22 years of experience. METHODOLOGY: Between 1974 and 1996 in 2 large Madrid hospitals we operated on 459 patients with 630 hydatid cysts. As technical advances and experience may vary results, patients were divided into 2 groups according to the period when they had undergone surgery: group A between 1974 and 1984; and group B between 1985 and 1996. Results of radical surgical resection and changes over the course of evolution of this technique were analyzed. RESULTS: A progressive drop was observed in morbidity and mortality. There were no deaths related to technical complications amongst total cystopericystectomy cases. Between 1990 and 1996 mortality was 0%, 2% of patients presented biliary fistula and 4% infection of the residual cavity. Mean hospital stay was 15.2 days. Only 1 patient of the 459 presented recurrence. CONCLUSIONS: As regards morbidity and mortality, technical advances and accumulated experience permit safe treatment of hepatic hydatid cysts by radical resection, with an almost nil recurrence rate. This makes it the technique of choice over others such as partial resection, PAIR or laparoscopy.

Intraductal papillary-mucinous tumors: an entity which is infrequent and difficult to diagnose.

BACKGROUND/AIMS: Intraductal papillary-mucinous tumor of the pancreas is currently considered to be a tumor which is an entity of its own, different from classic pancreatic ductal carcinoma. It is basically characterized by slow growth and low malignancy potential, as well as by the production of mucin. The aim of this study is to contribute to world literature some clarification of its natural history, clinical presentation, the most useful diagnostic tests, methods of detection of stromal invasion and handling of treatment. METHODOLOGY: Of 297 pancreatectomies undertaken at the "12 de Octubre" hospital between May 1985 and January 1998, only 1 case of Intraductal papillary-mucinous tumor was found. We have revised 127 cases published in 10 series over the last 10 years. We also contribute a review of our own case. RESULTS: These tumors, which are very infrequent, produce non-specific symptoms, with long latency periods from the first symptom up to stromal invasion. Endoscopic retrograde cholangiopancreatography showed alterations in 100% of cases where this was undertaken. Tumor-related mortality was zero amongst patients with non-invasive tumor who underwent surgery. None of the cases published presented upper gastrointestinal hemorrhage. This indicated the correct surgery and led us to our diagnosis. CONCLUSIONS: We confirm the low frequency and difficulty of diagnosis, the sensitivity of endoscopic retrograde cholangiopancreatography, the difficulty of early detection of stromal invasion, and the high survival rate in cases where resection is done before this occurs. Early diagnosis and treatment is therefore of utmost importance.