Investigation and control of aspergillosis and other filamentous fungal infections in solid organ transplant recipients.

Filamentous fungal infections are associated with high morbidity and mortality in solid organ transplant patients, and prevention is warranted whenever possible. An increase in invasive aspergillosis was detected among solid organ transplant recipients in our institution during 1991-92. Rates of Aspergillus infection (18.2%) and infection or colonization (42%) were particularly high among lung transplant recipients. Epidemiologic investigation revealed cases to be both nosocomial and community-acquired, and preventative efforts were directed at both sources. Environmental controls were implemented in the hospital, and itraconazole prophylaxis was given in the early period after lung transplantation. The rate of Aspergillus infection in solid organ transplant recipients decreased from 9.4% to 1.5%, and mortality associated with this disease decreased from 8.2% to 1.8%. The rate of Aspergillus infection or colonization among lung transplant recipients decreased from 42% to 22.5%; nosocomial Aspergillus infection decreased from 9% to 3.2%. Cases of aspergillosis in lung transplant recipients were more likely to be early infections in the pre-intervention period. Early mortality in lung transplant recipients decreased from 15% to 3.2%. Two cases of dematiaceous fungal infection were detected, and no further cases occurred after environmental controls. The use of environmental measures that resulted in a decrease in airborne fungal spores, as well as antifungal prophylaxis, was associated with a decrease in aspergillosis and associated mortality in these patients. Ongoing surveillance and continuing intervention is needed for prevention of infection in high-risk solid organ transplant patients.

Gallbladder carcinoma producing alpha-fetoprotein.

Alpha-feto protein (AFP) is a clinically useful marker for hepatocellular carcinoma, hepatoblastoma, and nonseminomatous testicular tumors. Elevated serum AFP can also occur with tumors of the gastrointestinal tract, pancreas, lung, kidney, and urachus. Serum AFP can also be minimally elevated in nonmalignant conditions including acute and chronic hepatitis, cirrhosis, and pregnancy. Reports of gallbladder carcinoma that elaborate AFP are extremely rare, and almost all represent papillary carcinomas. Until now, there have been only two reports in the world literature that describe undifferentiated gallbladder carcinoma with elevated serum AFP. The authors present one case of undifferentiated gallbladder carcinoma and another case of poorly differentiated gallbladder carcinoma with increased serum AFP. In both cases, serum AFP was particularly useful in documenting metastatic recurrence of gallbladder carcinoma.

Anesthetic considerations in patients undergoing percutaneous radiofrequency interstitial tissue ablation.

Radiofrequency (RF) interstitial tissue ablation is a new, minimally invasive procedure for patients with liver cancer who are not candidates for conventional therapy. The percutaneous RF ablation therapy involves placing a needle electrode under ultrasound guidance into a selected portion of the tumor and heating the tissue between 90 degrees C and 100 degrees C. The ablation procedure can be done under monitored anesthesia care on an outpatient basis. The patient's ability to cooperate with regard to breathing is critical for accurate needle placement. Intravenous sedation must be meticulously titrated to maintain a delicate balance of patient cooperation and optimal comfort.

Exposure to Mycobacterium tuberculosis (MTB) in a renal transplant candidate: what further preoperative screening tests are available?

Despite negative preoperative screening for MTB, a renal candidate demonstrated active tuberculous lymphadenitis (TL) in a deep iliac node intraoperatively during living related renal transplantation. With intraoperative discovery of TL, both donor nephrectomy and renal transplant were aborted. The authors present this case of TL to discuss whether additional preoperative screening tests are available to document previous exposure to MTB in a renal transplant candidate. The diagnosis and treatment of MTB in patients on routine hemodialysis are reviewed. The authors review the operative case to emphasize that critical intraoperative measures must be taken to minimize operative and postoperative morbidity in the donor and recipient. Finally, the literature for current antibiotic regimens in the treatment of TL is reviewed.

Endoscopic biliary stent migration with small bowel perforation in a liver transplant recipient.

Intestinal perforation from a migrated biliary stent is a rare complication after endoscopic stent placement for benign biliary stricture. We provide the first description of stent migration and distal small-bowel perforation after stent placement for biliary anastomotic stricture in a liver transplant recipient. We review the current literature on the diagnosis and management of stent migration and intestinal perforation after endoscopic or percutaneous stent placement for benign and malignant biliary strictures. Early diagnosis and treatment of biliary stent migration and subsequent intestinal perforation are essential in transplant patients, in whom immunosuppression sometimes blunts signs and symptoms of intestinal perforation.

Endothelin-stimulated nitric oxide production in the isolated Kupffer cell.

Endothelin (ET) is a potent peptide mediator exhibiting a wide variety of effects in both the parenchymal and nonparenchymal hepatic cells. In the Kupffer cell, ET activates several transmembrane signaling pathways to generate numerous second messengers including the phospholipase C-generated products inositol-1,4,5-trisphosphate and diacylglycerol and the cyclooxygenase product prostaglandin E2 via specific ETB-type receptors. In addition to these findings, we have now demonstrated that endothelin stimulates the production of nitric oxide (NO) in the Kupffer cell in a time- and concentration-dependent manner. Western blot analysis indicates that ET-stimulated NO production occurs though activation of the inducible form of the nitric oxide synthase enzyme. These findings have important implications as the stimulation of NO production by ET may be part of the physiological response to inflammation or infection. Elevated levels of ET and NO have been found to be associated with numerous hepatic pathophysiological conditions that may contribute to derangements in the vascular system seen in these conditions.

Renal allograft torsion associated with prune-belly syndrome.

We report a 26-month-old child diagnosed with prune-belly syndrome and end-stage renal disease who received intraperitoneal implantation of an adult cadaveric renal graft which functioned very well for approximately 6 weeks. The patient then presented with acute renal failure which was proved to be secondary to torsion of the graft, twisting the artery and vein. The ureter was wrapped 360 degrees around the graft. These conditions resulted in loss of the graft and nephrectomy. Ours is the second report of such an occurrence; the first was from a living-related kidney donor. We believe the lack of abdominal wall tone contributes to graft mobility and risk of torsion of the kidney. We recommend that nephropexy be considered in these patients. In addition, the risk of torsion must be at the forefront of the differential diagnosis in a prune-belly renal transplant patient with acute onset of oliguria. Renal sonography with Doppler should be employed as soon as possible so that the graft can be saved.