Outcomes and factors influencing prognosis in patients with vascular pythiosis.

OBJECTIVE: Vascular pythiosis, caused by Pythium insidiosum, is associated with a high mortality rate. We reviewed the outcomes and established the factors predicting prognosis of patients treated in our institution with surgery, antifungal therapy, or immunotherapy. METHODS: We undertook a retrospective record review of patients with vascular pythiosis treated in Siriraj Hospital, Bangkok, Thailand, between January 2005 and January 2015. Patient characteristics, type of surgery, adjunctive antifungal treatment, adjunctive immunotherapy, and disease status of surgical arterial and surrounding soft tissue margins were recorded. We calculated the mortality rate and established factors predicting prognosis. RESULTS: The records of 11 patients were reviewed. All patients had thalassemia. Nine patients (81.8%) had a history of contact with contaminated water. The clinical presentations were chronic ulcers (45.5%), toe gangrene (27.3%), pulsatile mass (27.3%), and acute limb ischemia (27.3%). Above-knee amputation was required in 10 patients (90.9%). The mortality rate was 36.4%. Independent variables between survivors and nonsurvivors were lack of an arterial disease-free surgical margin (P = .003), lack of a surrounding soft tissue disease-free surgical margin (P < .05), a suprainguinal lesion (P < .05) and duration of symptoms (P < .05). Adjuvant itraconazole, terbinafine, and Pythium vaccine have a role to play in patients with a disease-free arterial surgical margin but in whom infected surrounding soft tissue could not be completely excised. CONCLUSIONS: Achieving adequate disease-free surgical margins-especially the arterial margin-at amputation or débridement is the most important prognostic factor in patients with vascular pythiosis. Early detection combined with a multidisciplinary approach to treatment, including surgery, antifungal agents, and immunotherapy, allows the best possible outcome to be obtained.

Hydatid cyst of the liver causing inferior vena caval obstruction.

Hydatid disease (cystic echinococcosis) is a zoonotic infection caused by larval forms of the tapeworm Echinococcus granulosus. Most common site for cysts is liver and hepatic hydatidosis has a diverse clinical spectrum. Mostly they remain asymptomatic and uncomplicated. Here we report a case of a 50 yr old farmer admitted for renal disease, who was incidentally found to have inferior vena caval obstruction. Ultrasound abdomen and CT abdomen were done and a 10 x 7 cms hepatic hydatid cyst compressing the vena cava was found.

Management and outcome of cardiac and endovascular cystic echinococcosis.

BACKGROUND: Cystic echinococcosis (CE) can affect the heart and the vena cava but few cases are reported. METHODS: A retrospective case series of 11 patients with cardiac and/or endovascular CE, followed-up over a period of 15 years (1995-2009) is reported. RESULTS: Main clinical manifestations included thoracic pain or dyspnea, although 2 patients were asymptomatic. Cysts were located mostly in the right atrium and inferior vena cava. Nine patients were previously diagnosed with disseminated CE. Echocardiography was the diagnostic method of choice, although serology, electrocardiogram, chest X-ray, computed tomography/magnetic resonance imaging and histology aided with diagnosis and follow-up. Nine patients underwent cardiac surgery and nine received long-term antiparasitic treatment for a median duration of 25 months (range 4-93 months). One patient died intra-operatively due to cyst rupture and endovascular dissemination. Two patients died 10 and 14 years after diagnosis, due to pulmonary embolism (PE) and cardiac failure, respectively. One patient was lost to follow-up. Patients who had cardiac involvement exclusively did not have complications after surgery and were considered cured. There was only one recurrence requiring a second operation. Patients with vena cava involvement developed PEs and presented multiple complications. CONCLUSIONS: Cardiovascular CE is associated with a high risk of potentially lethal complications. Clinical manifestations and complications vary according to cyst location. Isolated cardiac CE may be cured after surgery, while endovascular extracardiac involvement is associated with severe chronic complications. CE should be included in the differential diagnosis of cardiovascular disease in patients from endemic areas.

Hydatid cyst of the pulmonary artery secondary to hepatic hydatid cyst embolism.

A cystic lesion of the liver extending into the inferior vena cava was discovered in a 33-year old female patient suffering from dyspnea, pain and swelling in the legs. Plain chest X-ray was normal. CT and MRI of the thorax showed a cystic lesion within the right pulmonary artery. The liver lesion was treated by a partial cystectomy and omentoplasty, inferior vena cava and bile ducts repair. Through a right thoracotomy, a hydatid cyst was found in the pulmonary artery and enucleated. Although very rare, pulmonary artery hydatidosis may be the cause of an unexplained dyspnea in patients with hydatidosis of the liver.

[Invasion of the portal vein by a hydatid cyst. Review of the literature]. / Fístula de quiste hepático hidatídico a vena porta: revisión de la literatura.

We have found only 3 publications in the literature that describe portal vein invasion by a hydatid cyst. This complication is very uncommon but should be kept in mind in the diagnosis of anaphylactic shock. Clinical presentation can vary from abdominal pain and fever to portal hypertension or anaphylactic reaction due to leaking of antigenic material from the cyst. Ultrasound and computed tomography scan can identify hydatid cysts and cavernomatosis, but magnetic resonance imaging shows the presence of multiple daughter vesicles replacing the lumen of the portal vein and a communication between the residual cyst and the portal vein. The treatment of choice is surgery, including removal of the cyst and local instillation of scolicide solution. In addition to surgery, administration of albendazole is recommended. Administration should begin 4 days before extirpation and should be continued for more than 4 weeks.

Reinfecçöes e desenvolvimento da fibrose periportal esquisomótica no modelo murino / Reinfections and the development of schistosomal periportal fibrosis in the murine model

A fibrose periportal esquistossomótica observada no modelo murino apareceu muito mais freqüentemente (69,2 por cento) em camundongos submetidos a múltiplas infecçöes pelo Schistosoma mansoni do que naqueles animais com infecçäo única (11,1 por cento). A contagem dos ovos depositados no fígado näo diferiu significativamente nos dois grupos ao término dos experimentos. Embora näo tenha ficado esclarecido o motivo pelo qual as infecçöes repetidas favorecem o desenvolvimento da fibrose periportal esquistossomótica, os dados observados fornecem apoio experimental às observaçöes clínico-epidemiológicas que sugerem ter as reinfecçöes um papel na patogenia da forma hepato-esplênica da esquistossomose

Improvement in pulmonary arterial lesions after heartworm removal using flexible alligator forceps.

Improvement of pulmonary arterial lesions after heartworm removal using flexible alligator forceps was investigated by measuring pulmonary arterial pressure (PAP), and by angiographic and histopathological examinations in 11 dogs. PAP obtained immediately after worm removal corresponded well with angiographic abnormalities. In 2 dogs, high PAP immediately after worm removal fell gradually by 12 weeks, and obstructions on angiogram were resolved at 4 to 12 weeks. In 4 dogs, slightly high PAP fell to the normal range at 4 weeks, and angiographic abnormalities were considerably reduced at 4 to 12 weeks. In 5 dogs, PAP returned to normal range immediately after worm removal, and angiographic changes almost disappeared at 4 to 8 weeks. On biopsy immediately after worm removal, samples of the main pulmonary arteries showed severe intimal proliferations with villous or papillary protrusion into the lumen. Autopsy at 12 to 20 weeks indicated that the intimal protrusions were remarkably reduced as compared with the biopsy samples in all cases. However, villous intimal protrusions were seen in the caudal lobar arteries in cases with remaining alive worms. New vessels seemed to develop into thromboemboli with time. From these findings, it is clear that the pulmonary arterial lesions improved after heartworm removal, and the clinical signs disappeared following the improvement in hemodynamics. Aspirin therapy (5 mg/kg/day) for 4 weeks after worm removal in 5 dogs did not improve the intimal lesions as compared to 3 control dogs.

Patogenesis of Pipe-stem fibrosis of the liver: experimental observation on murine Schistosomiasis

Camundongos infectados com 30 cercárias do Schistosoma mansoni desenvolveram fibrose porta em virtude de um depósito progressivo e concentrado de ovos na regiäo periportal, o que aconteceu a partir da 16ª semana da infecçäo. Esta fibrose certas características da chamada fibrose "pipe-stem" do homem vista na forma hepatoesplênica da esquistossomose, tais como obstruçäo das radiculas porta, telangiectasia, conexäo fibrosa entre espaços porta e entre estes e veias centrais, além de certo grau de fibrose septal, presença dos granulomas em várias fases evolutivas e reaçäo inflamatória crônica difusa, enquanto o parênquima hepático mantinha a sua estrutura lobular normal. As técnicas de injeçäo vascular com tinta da China e com vinilite feitas no sistema porta permitiram a elucidaçäo do mecanismo da concentraçäo de ovos (e conseqüentemente de fibrose) nos espaços porta. Observou-se que após certo tempo da infecçäo, abrem-se colaterais que saem diretamente em ângulo reto dos principais ramos porta. Após a 16ª semana de infecçäo em diante, os ovos tendem a se depositar nestas colaterais, ao invés de se distribuírem difusamente nos finos ramos terminais como acontece antes deste período. A fibrose "pipe-stem" do camundongo tem muitas semelhanças com a lesäo humana, embora näo seja facilmente demonstrável macroscopicamente, tudo indicando que se desenvolva na base de uma mesma patogenia

Pathogenesis of pipe-stem fibrosis of the liver (experimental observation on murine schistosomiasis).

Mice infected with 30 cercariae of Schistosoma mansoni developed portal and septal fibrosis due to the massive and concentrated deposition of eggs in the periportal areas which occurred following the 16th week after infection. The lesion resembled pipe-stem fibrosis seen in human hepatosplenic schistosomiasis in the following characters: portal fibrosis interconnecting portal spaces as well as portal spaces and central canals; portal inflammation; periovular granulomas; vascular obstruction and telangiectasia. The liver parenchyma maintained its normal architecture. Vascular injection techniques with Indian ink and vinylite revealed that the portal system developed numerous dilated collateral venules coming from the large and medium-sized portal branches, about 10 weeks after schistosome infection. The lodging of schistosome eggs into these collaterals resulted in granulomatous inflammation and fibrosis along all the portal tracts, thus forming the pipe-stem lesion. Although not readily demonstrable grossly, the pipe-stem fibrosis of murine schistosomiasis has many similarities with the human lesion and can be considered to have the same basic pathogenesis.