[Cryptic Aspergillus species - a case report of chronic cavitary pulmonary Aspergillus lentulus infection in a heart transplant recipient].

Cryptic species within the section Fumigati, that is Aspergillus fumigatus-like species, are increasingly reported in the literature as causative agents of invasive aspergillosis (IA) in both humans and animals. Their detection and proper identification are important, but even more important is to determine the susceptibility profile (minimum inhibitory concentrations, MICs) of the isolate to antifungals using appropriate methods. Cryptic species often demonstrate elevated MICs to drugs recommended for IA therapy such as voriconazole or amphotericin B. Presented is a case of pulmonary aspergillosis in a 63-year-old male heart transplant recipient. Aspergillus lentulus with reduced susceptibility to voriconazole and amphotericin B was identified as the causative agent of the infection using culture and DNA sequencing. Susceptibility to antifungals was confirmed by the standard EUCAST-AFST methods. Based on MIC values obtained in vitro, therapy was switched from voriconazole to posaconazole with excellent clinical effects. To the best of our knowledge, this is the first reported case of A. lentulus infection treated with posaconazole and, moreover, a successful one.

Successful Posaconazole Therapy of Disseminated Alternariosis due to Alternaria infectoria in a Heart Transplant Recipient.

We report a case of phaeohyphomycosis caused by Alternaria infectoria in a 61-year-old heart transplant recipient with multiple skin lesions and pulmonary infiltrates. The infection spread via the haematogenous route from the primary cutaneous lesions into the lungs. The diagnosis was based on the histopathological examination, direct microscopy, skin lesion cultures and detection of Alternaria DNA in the bronchoalveolar lavage fluid using molecular methods. The treatment consisted of a combination of surgical excision and systemic antifungal therapy. Voriconazole was the first agent used but had a weak effect. Posaconazole was subsequently used to achieve a successful response. The isolate was identified as A. infectoria by sequencing of the rDNA ITS region and the partial ß-tubulin gene.

[Intestinal transplantation in Czech Republic]. / Transplantace tenkého streva v Ceské republice.

Intestinal transplantation represents a suitable treatment for patients with intestinal failure who then develop life-threatening complications of total parenteral nutrition and for some patients with complex abdominal disorders not suitable for conventional treatment. METHODS: prior to launch of the clinical program, preparation started in 2006 initially with extensive experimentation carried out on pigs. The clinical phase involved a specialized, multidisciplinary team who examined 23 patients being considered for transplantation. Seven patients were put on a waiting list and one female, due to the improvement of her medical status, was unlisted. The first ever intestinal transplantation was done in 2014. RESULTS: three out of six transplanted patients are alive with 380 days of actual survival; median 131 days (63-763). Two patients are on a full oral diet and nutritionally independent with an excellent quality of life. One female is nutritionally independent but with the need for partial supplemental parenteral rehydration due to the stomal output. CONCLUSION: intestinal transplantation is a suitable treatment for highly selected patients with intestinal failure who meet specific listing criteria.

Radiologic Evaluation of Uterine Vasculature of Uterus Transplant Living Donor Candidates: DUETS Classification.

Uterus transplantation is a treatment solution for women suffering from absolute uterine factor infertility. As much as 19.5% of uterus-transplanted patients underwent urgent graft hysterectomy due to thrombosis/hypoperfusion. The necessity to identify candidates with high-quality uterine vasculature is paramount. We retrospectively evaluated and compared the imaging results with actual vascular findings from the back table. In this article, we present a novel radiologic grading scale (DUETS classification) for evaluating both uterine arteries and veins concerning their suitability for uterus procurement and transplantation. This classification defines several criteria for arteries (caliber, tapering, atherosclerosis, tortuosity, segment, take-off, and course) and veins (caliber, tapering, plethora, fenestrations, duplication/multiplicity, dominant route of venous drainage, radiologist's confidence with imaging and assessment). In conclusion, magnetic resonance angiography can provide reliable information on uterine venous characteristics if performed consistently according to a well-established protocol and assessed by a dedicated radiologist. The caliber of uterine arteries seems to be inversely related to the time passed since the last delivery. We recommend that the radiologist comments on the reliability and confidence of the imaging study. It cannot be over-emphasized that the most crucial aspect of surgical imaging is the necessity of high-quality communication between a surgeon and a radiologist.

An embolus in the right atrium caught in the Chiari network and resistant to thrombolysis.

Case report is presented, which describes a patient with thromboemboli trapped in the Chiari network within the right heart and resistant to thrombolysis. The right atrial masses were completely removed under cardiopulmonary bypass. Histological evaluation confirmed a mixed thromboemboli, with thrombus structures showing signs of organization and surrounded by a fibrous capsule. A heterozygous methylenetetrahydrofolate reductase gene polymorphism was found, and the plasma level of the plasminogen activator inhibitor type-1 (PAI-1) was 50% higher than the normal upper limit. In this presented case, the Chiari network displayed a protective function, but the expansion and organization of the thromboembolus caught there made it resistant to lytic therapy. Another important factor which could have influenced the resistance to thrombolysis was the high level of PAI-1. PAI-1 is the primary physiologic inhibitor of plasminogen activation in blood. Elevated pre-treatment levels of PAI-1 may reduce the efficacy of thrombolytic therapy by preventing or retarding clot dissolution. The patient's DNA was tested for a common single-base-pair polymorphism (four or five guanine bases) in the promoter region of the gene (4G/5G), but the presence of this variant allele was not confirmed: the patient was homozygous for the 5G allele (5G/5G genotype).

Coronary calcium score in renal transplant recipients.

BACKGROUND: Coronary calcium score (CCS) is established as an index for the risk of coronary heart disease (CHD). The aim of this prospective study was to assess changes in CCS in patients 1 year after kidney transplantation (KTx). METHOD: A total of 221 consecutive renal transplant recipients were enrolled in our prospective study (140 males/81 females). CCS was analyzed by spiral multidetector CT at baseline and 1 year after KTx. Bone mineral density (BMD) was measured in the lumbar spine (L-BMD) and femur (F-BMD). RESULTS: The mean CCS was 539 +/- 1,033 at baseline. 33% of the patients had a CCS of 0, and 33% of patients had a CCS of >401. A negative correlation was found between F-BMD and CCS, but no correlation was found between L-BMD and CCS. Using CCS, a positive correlation was found between total cholesterol and the age of patients, but no correlation of CCS was found with other biochemical markers of bone and lipid metabolism. One year after transplantation, the mean CCS was 703 +/- 1,253; in 75% of patients the CCS was the same and 25% had a higher CCS. CONCLUSION: A high risk of CHD was found in 33% of renal graft recipients. No improvement in CCS was found 1 year after KTx.

Assessment of left ventricular function in non-dilated and dilated hearts: comparison of contrast-enhanced 2-dimensional echocardiography with multi-detector row CT angiography.

OBJECTIVE: Multidetector-row CT (MDCT) and contrast-enhanced echocardiography (CEE) are being increasingly used for assessment of left ventricular (LV) function. Excellent spatial and contrast resolution of MDCT allows this evaluation along with coronary angiography. CEE improves the accuracy of 2D echocardiography. Data on side-by-side comparison of both techniques for assessment of LV size and function in subjects with a non-dilated or dilated left ventricle are limited. METHODS AND RESULTS: Our study population included 64 patients. Group I included 31 patients with an implanted pacemaker who had a non-dilated left ventricle with preserved systolic function. Group II comprised 33 patients with dilated cardiomyopathy and severe systolic LV dysfunction. LV end-diastolic and end-systolic volumes (LVEDV, LVESV) and ejection fraction (LVEF) were assessed using both CEE and short-axis MDCT. The results obtained by both techniques were compared by linear regression and Bland-Altman analysis. Additionally, intra- and interobserver reproducibility was assessed. Both CEE and MDCT measurements highly correlated (r = 0.61-0.94). However, CEE significantly underestimated LVEDV and LVESV, and this bias was higher with enlarged LV volumes. LVEF was overestimated by CEE in both groups with a higher bias in the group with preserved systolic function. Both intra- and interobserver reproducibility was significantly better for MDCT, the worst reproducibility was observed for CEE in group I. CONCLUSION: Despite a high correlation between MDCT and CEE measurements, CEE provides consistently lower volumes and higher LVEF. This suggests that both methods are not completely interchangeable. Reproducibility of CEE is inferior to reproducibility of MDCT, especially in non-dilated left ventricles with preserved function.

Successful Treatment of Iron-Overload Cardiomyopathy in Hereditary Hemochromatosis With Deferoxamine and Deferiprone.

There is scarce evidence regarding the use of iron chelators in patients with hereditary hemochromatosis who are intolerant of phlebotomy or erythrocytapheresis. A 52-year-old man with genetically confirmed HFE hemochromatosis presented with liver disease and heart failure with severe left ventricular systolic dysfunction. Because of anemia after initial treatment, we added intravenous deferoxamine followed by oral deferiprone to less frequent erythrocytapheresis, which normalized systolic function within 1 year. Repeated cardiac magnetic resonance imaging revealed improvement of the T2* relaxation time. This report illustrates the beneficial effect of iron chelators in individuals with HFE hemochromatosis and poor tolerance of erythrocytapheresis.

Utility of combination of cardiac magnetic resonance imaging and high-sensitivity cardiac troponin T assay in diagnosis of inflammatory cardiomyopathy.

We evaluated the clinical utility of cardiac magnetic resonance imaging (CMR) combined with a novel high-sensitivity troponin T assay (hs-cTnT) in the diagnosis of inflammatory cardiomyopathy. CMR, measurement of hs-cTnT, and endomyocardial biopsy were performed in 42 patients with dilated cardiomyopathy and a short-term history of heart failure (median 2 months, interquartile range 1 to 3.5). The patients were followed up for 25 ± 9 months for events. Endomyocardial biopsy revealed myocarditis in 15 subjects (36%). The sensitivity, specificity, and diagnostic accuracy of the individual CMR tissue parameters for myocardial inflammation was 40%, 96%, and 76% for early gadolinium enhancement, 87%, 44%, and 60% for late gadolinium enhancement, 47%, 89%, and 74% for pericardial effusion, and 67%, 85%, and 79% for any 2 of the criteria simultaneously, respectively. An assessment of myocardial edema on T(2)-weighted imaging and/or hs-cTnT assay were inadequate for the diagnosis. The extent of late gadolinium enhancement and increased hs-cTnT concentration were significant predictors of a composite end point of cardiac death, urgent heart transplantation, and hospitalization for worsening heart failure (hazard ratio 1.1, 95% confidence interval 1.0 to 1.2, per percentage of left ventricular mass; and hazard ratio 2.2, 95% confidence interval 1.4 to 3.5, per ln ng/L; p = 0.008 and p = 0.001, respectively). In conclusion, the results of the present study have demonstrated a modest performance for CMR and a limited use of the hs-cTnT assay in the diagnosis of inflammatory cardiomyopathy. Nonetheless, in these patients, CMR and/or hs-cTnT assessment seems to be useful for the prediction of the clinical outcome.

Novel predictors of left ventricular reverse remodeling in individuals with recent-onset dilated cardiomyopathy.

OBJECTIVES: This study aimed to evaluate the performance of cardiac magnetic resonance (CMR), cardiac biomarkers, and endomyocardial biopsy (EMB) results to predict left ventricular reverse remodeling (LVRR) in individuals with recent-onset dilated cardiomyopathy (DCM). BACKGROUND: LVRR is a marker of a favorable prognosis in individuals with recent-onset DCM. We used the aforementioned novel methods of prognostication to predict this event. METHODS: A total of 44 consecutive patients with recent-onset DCM underwent at baseline CMR, measurement of biomarkers and EMB together with conventional methods, including cardiopulmonary exercise testing and echocardiography. Measurement of B-type natriuretic peptide (BNP) and the cardiological examination were repeated at 3, 6, and 12 months. CMR was repeated at 12 months. LVRR was defined as an absolute increase in left ventricular ejection fraction from ≥10% to a final value of >35% accompanied by a decrease in left ventricular end-diastolic dimension ≥10% at 12 months of follow-up. RESULTS: LVRR was observed in 20 individuals (45%) at 12 months. At baseline, a lower extent of late gadolinium enhancement (odds ratio [OR]: 0.67 [95% confidence interval (CI): 0.50 to 0.90]; p = 0.008) and a higher myocardial edema ratio (OR: 1.45 [95% CI: 1.04 to 2.02]; p = 0.027) measured by CMR were independent predictors of LVRR. At 3 months, the latest BNP plasma level (OR: 0.14 [95% CI: 0.02 to 0.94] per log BNP; p = 0.047) was the strongest predictor of LVRR. CONCLUSIONS: Both CMR and serial BNP testing provide a better prediction of LVRR in recent-onset DCM than EMB results, other biomarkers, and the conventional methods of follow-up.

A complex anomaly of systemic and pulmonary venous return associated with sinus venosus atrial septal defect.

This report describes a rare case of anomalous systemic and pulmonary venous return that was surgically corrected. It consisted of left inferior vena cava with hemiazygous continuation into the persistent left superior vena cava, partial anomalous pulmonary venous return from the right lung and sinus venosus atrial septal defect.

The anomalous origin of the left coronary artery from the right aortic sinus: is the coronary angiography still a 'gold standard'?

Coronary artery anomalies remain a poorly understood topic in modern cardiology. The most important issue is the origin of the left coronary artery or the left anterior descending artery from the opposite aortic sinus, frequently associated with sudden cardiac death. We report our experience concerning the evaluation of these anomalies. From 15 April 1997 to 1 December 2004, we performed 13.407 coronary angiographies and found eight patients with these anomalies. In seven patients the coronary angiography was sufficient for the ultimate decision. However, in one case was the angiographic signs contradictory and the optimal imaging of the coronary tree was received by the multi-slice spiral computer tomography. We consider the coronary angiography a sufficient method of evaluation in most of the patients with the coronary artery anomalies, but the 'gold standard' is 3-dimensional examination by the multi-slice computer tomography or the magnetic resonance. The computer tomography is the method of the choice to distinguish interarterial, intraseptal and prepulmonary course of the left coronary artery originating from the right aortic sinus.