Infectious complications of bronchial stenosis in lung transplant recipients.

BACKGROUND: Bronchial stenosis is a known complication of lung transplantation, but there are limited data regarding whether transplant recipients with bronchial stenosis develop more infectious complications than those without bronchial stenosis. METHODS: We conducted a retrospective single-center observational cohort study between January 1, 2011 and September 29, 2016 of 35 lung transplant recipients diagnosed with bronchial stenosis and a random sample of 35 lung transplant recipients without bronchial stenosis. Data collected included donor/recipient demographic and anatomic information, respiratory cultures, episodes of respiratory infections diagnosed using CDC-NNIS criteria, hospitalizations, and 1-year all-cause mortality. Patients were followed up to 1 year after transplant. RESULTS: Bronchial stenosis occurred at a median of 54 days post-transplant (range 5-365 days). Bronchial stenosis patients spent more time in the hospital (87.4 vs 46.8 days, P = 0.011) and had more total hospitalizations (4.54 vs 2.37, P < 0.01) than their counterparts. The relative risk of pneumonia among cases vs controls was 4.0 (95% CI 2.2-7.3, P < 0.01); for purulent tracheobronchitis the relative risk was 3.1 (95% CI 1.6-6.1, P < 0.01). Patients with bronchial stenosis were significantly more likely to have respiratory cultures growing Staphylococcus aureus (RR 5.0; P = 0.001) and Pseudomonas aeruginosa (RR 2.1, P = 0.026). Mortality within the first year following transplant was equal in both the groups (14.3% vs 14.3%). CONCLUSIONS: There was no significant increase in 1-year mortality for lung transplant patients who developed bronchial stenosis. However, bronchial stenosis patients had significantly higher risks of pneumonia and tracheobronchitis, and spent more days in the hospital than those without bronchial stenosis.

Characteristics of fecal microbial communities in patients with non-anastomotic biliary strictures after liver transplantation.

AIM: To explore the possible relationship between fecal microbial communities and non-anastomotic stricture (NAS) after liver transplantation (LT). METHODS: A total of 30 subjects including 10 patients with NAS, 10 patients with no complications after LT, and 10 non-LT healthy individuals were enrolled. Fecal microbial communities were assessed by the 16S rRNA gene sequencing technology. RESULTS: Different from the uncomplicated and healthy groups, unbalanced fecal bacterium ratio existed in patients with NAS after LT. The results showed that NAS patients were associated with a decrease of Firmicutes and Bacteroidetes and an increase of Proteobacteria at the phylum level, with the proportion-ratio imbalance between potential pathogenic families including Enterococcaceae, Streptococcaceae, Enterobacteriaceae, Pseudomonadaceae and dominant families including Bacteroidaceae. CONCLUSION: The compositional shifts of the increase of potential pathogenic bacteria as well as the decrease of dominant bacteria might contribute to the incidence of NAS.

Cytopathology of Hepatobiliary-Related Actinomycosis.

BACKGROUND: The clinical diagnosis of hepatobiliary-related actinomycosis can be challenging owing to its rarity and variable presentation. Moreover, actinomycotic pseudotumors may mimic malignancy and result in unnecessary surgical resection. Herein, we present the clinical and cytopathological features of 3 cases with hepatobiliary-related actinomycosis. CASES: The first patient was a 73-year-old man who presented with an exophytic liver lesion. The second patient was a 78-year-old woman who presented with a biliary stricture. The third patient was an 88-year-old woman with a right flank mass extending to the liver. The aspirate smears in these 3 cases demonstrated 'cotton ball' clusters of filamentous microorganisms and abscesses. The cell blocks of 2 of the patients showed sulfur granules with peripheral filamentous microorganisms positive with a Gram stain but negative with an acid fast stain, consistent with Actinomyces species. All patients were elderly and shared a past surgical history of laparoscopic cholecystectomy. CONCLUSION: These cases demonstrate the complementary role of cytology in the diagnosis of hepatobiliary actinomycosis. A cytologic diagnosis of actinomycosis is minimally invasive and quick. It can prompt proper culture medium selection and avoid unnecessary or extensive surgery. Based on our experience, laparoscopic cholecystectomy may be a precipitating factor for the subsequent development of hepatobiliary-related actinomycosis.

[MICROBIAL LANDSCAPE OF BILE IN PATIENTS WITH AN ACUTE PURULENT CHOLANGITIS].

Bacteriological analysis was conducted in 136 patients with an acute purulent cholangitis (APCH). The APCH causes were: choledocholithiasis--in 40 (29.9%) patients, coexistence of a common biliary duct stricture and choledocholithiasis--in 39 (28.7%), compression of external biliary ducts by the oedematous pancreatic head in secondary pancreatitis--in 15 (11%), pericholedocheal lymphadenitis--in 3 (2.2%).

Effect of Helicobacter pylori on marginal ulcer and stomal stenosis after Roux-en-Y gastric bypass.

BACKGROUND: Conflicting data have been published regarding whether Helicobacter pylori (HP) positivity is associated with increased complication rates in patients undergoing Roux-en-Y gastric bypass (RYGB). METHODS: We retrospectively examined the rate of complications in patients undergoing RYGB according to preoperative HP positivity and persistent post-treatment positivity to determine whether a correlation exists. RESULTS: A total of 228 patients underwent RYGB during a 2-year period (2009-2011). No patient had evidence of active ulcer disease on preoperative endoscopy. Of the 228 patients, 68 tested positive for HP on serum antigen screening and were treated with omeprazole, clarithromycin, and amoxillin. After treatment, 24 patients were persistently positive on repeat endoscopic biopsy. Of the 228 patients, 12 experienced a total of 13 complications (stomal stenosis in 8, marginal ulcer in 5, and none with anastomotic leak or gastrointestinal bleeding). Of the 68 patients with HP positivity preoperatively, 1 complication (2.3%) developed in the 44 patients who had responded to triple therapy, and no complications occurred in the 24 patients who had remained positive after treatment (P = 1.00), showing no difference. Also, no significant difference was found in the rate of complications (P = .11) between patients who were HP negative preoperatively (11 of 160, 6.9%) and those who were positive preoperatively (1 of 68, 1.5%). CONCLUSION: HP status, whether positive preoperatively or persistently positive after treatment, had no effect on the marginal ulcer or stomal stenosis rates in patients undergoing RYGB in the present study.

Endobronchial tuberculosis: an overview.

Endobronchial tuberculosis (EBTB), of which the incidence has been increasing in recent years, is a special type of pulmonary tuberculosis. The endobronchial tuberculose focuses often injure the tracheobronchial wall and lead to tracheobronchial stenosis. The tracheobronchial stenosis may cause intractable tuberculosis and make patients become chronic infection sources of tuberculosis, or may even cause pulmonary complications and result in death. The etiological confirmation of Mycobacterium tuberculosis is most substantial for diagnosis. However, because the positive rate of acid-fast bacillus staining for sputum smears is low and the clinical and radiological findings are usually nondistinctive, the diagnosis of EBTB is often mistaken and delayed. For early diagnosis, a high index of awareness of this disease is required and the bronchoscopy should be performed as soon as possible in suspected patients. The eradication of Mycobacterium tuberculosis and the prevention of tracheobronchial stenosis are two most substantial treatment goals. To get treatment goals, the diagnosis must be established early and aggressive treatments must be performed before the disease progresses too far.

Liver transplantation in management of alveolar echinococcosis: two case reports.

Hepatic alveolar echinococcosis is an infectious disease caused by the larval stage of Echinococcus multilocularis, which grows primarily in the liver of an infected person and develops as a tumorlike lesion. In advanced cases, the organisms infiltrate every organ neighboring the liver and spread hematogenously to distant organs such as lungs and brain. Surgical resection and liver transplantation are accepted treatment options for early and advanced disease, respectively. Herein, we present case reports of 2 patients with advanced alveolar echinococcal disease that invaded both lobes of the liver and neighboring vital structures including the inferior vena cava. Despite the technical difficulty of the surgery, both patients were successfully treated with living donor liver transplantation. Liver transplantation should be accepted as a life-saving treatment of choice in patients with alveolar echinococcosis for whom there is no other medical or surgical treatment options.

Biliary candida infections in primary sclerosing cholangitis.

BACKGROUND/AIMS: Patients with Primary Sclerosing Cholangitis (PSC) frequently develop dominant stenoses of the bile ducts and bacterial infections represent a major problem in such patients. In the present study, the role of fungal infections of the bile ducts has been evaluated. METHODS: In a prospective non-randomized trial, in 67 consecutive patients with PSC, 148 bile samples, each taken at one endoscopic examination, were microbiologically analysed. RESULTS: Candida species were found in 8/67 patients whereas Aspergillus was not detected. Seven patients with biliary Candida had a dominant stenosis and one had a wide papillotomy with chronic ascending cholangitis. Altogether 7/49 of patients with dominant stenosis and 1/18 of patients without dominant stenosis had Candida in their bile. All patients with biliary Candida intermittently had received antibiotics and had advanced disease with cholestasis. Candida disappeared spontaneously in 2/7 patients, cleared after antifungal treatment in 2, and persisted in 3 patients. Patients with biliary Candida had more severe cholangitis with higher CRP and serum bilirubin compared to those without Candida infection. CONCLUSIONS: This is the first report on the identification of Candida species in the bile of patients with PSC. Apart from bacterial also fungal infection of the bile ducts should be considered in the treatment of such patients.

Tuberculous colonic strictures: impact of dilation on diagnosis.

BACKGROUND AND STUDY AIM: Colonic strictures are commonly encountered in patients with colonic tuberculosis. If the colonoscope cannot be negotiated past the stricture the procedure is abandoned, the colonic mucosa proximal to the stricture cannot be inspected, and therefore lesions in these locations may be missed. PATIENTS AND METHODS: 130 patients with colonic tuberculosis were studied. Of these 22 (17 %) had impassable colonic strictures. These strictures were dilated, the colonic mucosa proximal to the strictures was then inspected, and biopsies were obtained from lesions of suspicious appearance. RESULTS: All strictures could be dilated. No abnormality was found in 11 patients. In the other 11 patients one or more additional findings were noted on colonoscopy after dilation. A second stricture was found in three patients. Nodularity and/or ulceration was observed in the colon proximal to the site of the primary stricture in ten patients. Dilation of the strictures and histological examination of the biopsy from target lesions of the proximal colon contributed to making the definitive diagnosis in five patients. The diagnosis was not altered in the remaining six patients. CONCLUSION: Dilation of colonic strictures facilitates inspection of the colonic mucosa proximal to the strictures, enabling biopsy of target lesions. This approach offers important diagnostic clues and confirmation of the diagnosis in several patients in whom lesions might be missed if strictures are not dilated.

Infected bilomas in liver transplant recipients: clinical features, optimal management, and risk factors for mortality.

BACKGROUND: Infected hepatic fluid collections (bilomas) are a major infectious complication of liver transplantation. Limited data exist on management and outcome of biloma. METHODS: We report a cohort study of 57 liver transplant recipients with posttransplantation bilomas undertaken to identify the clinical features of biloma, management strategies, and outcome. RESULTS: Fever (44%) and abdominal pain (40%) were the most common presenting symptoms, but one-third of patients were asymptomatic; 79% had elevated hepatic enzyme levels. Patients without hepatic artery thrombosis (HAT) had the highest rates of resolution with percutaneous drainage and anti-infective therapy (64%). Retransplantation was necessary in 64% of patients with HAT and biloma. Independent predictors of resolution with nonsurgical therapy were absence of HAT (odds ratio [OR] 7.69; P=.01) and absence of Candida (OR, 9.09; P=.02) or enterococcal infection (OR, 7.69; P=.03). Patients with bilomas had significantly greater mortality (Cox proportional hazard ratio [HR], 2.38; P=.008, by log rank test) and graft loss (HR, 4.31; P<.0001). Predictors of mortality by multivariable analysis included renal insufficiency (OR, 12.51; P=.02) or infection with Candida species (OR, 4.93; P=.03) or gram-negative bacilli (OR, 9.12; P=.01). CONCLUSION: Posttransplantation biloma should be suspected in patients with fever or abdominal pain or abnormalities of hepatic enzymes, and it can be confirmed by computerized tomography and radiographically guided aspiration. Bilomas are most likely to be successfully treated nonsurgically in patients without HAT and without Candida or enterococcus infection.

Experimentally induced teat stenosis in dairy ewes: clinical, pathological and ultrasonographic features.

A strain of Staphylococcus chromogenes was introduced into the teat cistern of five ewes, teat inflammation and stenosis being the primary consequences. Initially, the inoculated teats were swollen and warm; later, a hard structure was palpated running lengthwise inside the teat, with a thick ring above the tip of the teat, which interfered with expression of milk. Mastitis, confirmed by clinical, cytological, bacteriological and histological findings, was evident 4 days after infection. Ultrasonographically, a hyperechoic line under the mucosa of the teat cistern was observed. At necropsy, the duct wall of the inoculated teats was found to be thickened. Histopathological features included leucocytic infiltration, especially under the mucosa of the teat, and extensive fibrosis in the subcutaneous tissues. S. chromogenes was recovered from scrapings from the duct and the cistern of the inoculated teats.

A rat model of otitis media with effusion caused by eustachian tube obstruction with and without Streptococcus pneumoniae infection: methods and disease course.

OBJECTIVE: To describe the clinical and histopathologic progression of a rat model of otitis media with effusion caused by eustachian tube obstruction (ETO) with and without Streptococcus pneumoniae infection. METHODS: In 164 rats, the left, bony eustachian tube was approached via a ventral incision and obstructed with dental material. Then 108 rats were infected via an intrabullar injection with S pneumoniae. At 48 hours, the infected rats were treated for 5 days with ampicillin. All ears were evaluated by weekly otomicroscopy. On each of days 1, 2, 7, 21, 35, 56, and 112, four rats were killed for histologic study. All effusions were cultured for bacteria. RESULTS: Fourteen rats died of surgical complications; effusion resolved by 2 weeks in 9 rats. During the first few days, infected ears with ETO had bulging tympanic membranes, followed by tympanic membrane retraction, purulent effusion, and otorrhea (50%) over the next few weeks, whereas uninfected ears with ETO developed retraction and serous effusion during the same time frame. At later times, all ears with ETO presented with retraction and serous or serous-mucoid effusion. S pneumoniae was recovered only from the infected ears with ETO (days 1 and 2), with some colonization by nonpathogenic microorganisms observed equally in both groups of ears. Histology showed a typical acute inflammatory reaction in the challenged ears with ETO through day 14 and then a chronic inflammation for all ears with ETO. CONCLUSION: The experimental methods provoked reproducible pathologic signs similar to those for otitis media with effusion. Given the availability of rat-specific reagents, this model is well suited for studies of cytokine elaboration during disease pathogenesis.

Percutaneous pulmonary artery and vein stenting: a novel treatment for mediastinal fibrosis.

Mediastinal fibrosis is a rare consequence of infection with the fungus Histoplasma capsulatum that can lead to occlusion of large pulmonary arteries and veins and mainstem bronchi. Medical and surgical treatments for this disorder have been ineffective. We describe successful treatment for central pulmonary arterial and venous obstruction due to mediastinal fibrosis in four patients using percutaneously placed intravascular stents. Patients were severely limited, World Health Organization functional class III or IV. At the time of right and left heart catheterization, stents were placed in pulmonary arteries (n = 1), veins (n = 2), or both (n = 1) to relieve vascular obstruction resulting from mediastinal fibrosis. Immediate hemodynamic and clinical improvement was observed in all patients. Three of the four patients have had sustained improvement in exercise tolerance, from 3.5 mo to 4.5 yr after stent placement. The only complication was a self-limited pulmonary hemorrhage in one patient. Our initial experience suggests that percutaneous stent placement to relieve central pulmonary arterial or venous obstruction due to mediastinal fibrosis is an effective new treatment modality.

Distribution of Chlamydia pneumoniae in the human arterial system and its relation to the local amount of atherosclerosis within the individual.

BACKGROUND: Chlamydia pneumoniae has been suggested to play a role in the origin of atherosclerosis. We studied the prevalence of C pneumoniae at multiple locations in the arterial system within the same individual. Studying the association between atherosclerosis and C pneumoniae within the individual excludes confounding by interindividual variability. METHODS AND RESULTS: Postmortem, the presence in the intima/plaque and media of C pneumoniae membrane protein was determined by use of a C pneumoniae-specific monoclonal antibody. In 24 individuals, 33 arterial locations were studied (n=738 segments). Area stenosis was determined in adjacent cross sections. In all individuals, immunostaining of C pneumoniae was observed in >/=1 artery. The highest prevalences were observed in the abdominal aorta (67%), internal and common iliac arteries (41%), and coronary arteries (33%). The lowest prevalences were observed in the radial (0%) and cerebral (2%) arteries. Within the individual, area stenosis was larger in cross sections with immunoreactivity compared with cross sections without immunoreactivity (31.0+/-11.9% versus 14.3+/-6.1%, respectively; P:<0.001). In the individual, immunoreactivity was observed in 15+/-10% of the arteries (range, 3% to 45%). Between individuals, the percentage of arteries with immunoreactivity to C pneumoniae was associated with the average area stenosis throughout the arterial system (r(2)=0.56, P:<0.001). CONCLUSIONS: C pneumoniae was mostly observed at locations that are related to clinically relevant features. Within the individual, the distribution of C pneumoniae is associated with the distribution of atherosclerosis. The role of the microorganism in atherosclerotic disease remains to be elucidated.

Beneficial effects of low-dose prostacyclin on cat intestinal perfusion during endotoxemia as evaluated with microdialysis and oxygen transport variables.

OBJECTIVE: To evaluate the effects of low-dose prostacyclin on intestinal perfusion during endotoxemia. DESIGN: A randomized, blinded experimental study. SETTING: A university laboratory. SUBJECTS: Sixteen anesthetized cats. INTERVENTIONS: The animals received endotoxin by continuous intravenous infusion (0.5 mg/kg plus 0.5 mg x kg(-1) x hr(-1)) and a continuous volume replacement throughout the experiment. Four hours after the start of endotoxin, the animals were randomized to receive an infusion of either prostacyclin at a dose of 1 ng x kg(-1) x min(-1) (prostacyclin group) or vehicle (control group) during the next 4 hrs. MEASUREMENTS AND MAIN RESULTS: Intestinal vascular resistance was calculated from systemic arterial pressure, central venous pressure, and superior mesenteric artery blood flow, and intestinal oxygen delivery and uptake were calculated from superior mesenteric artery and vein blood samples and blood flow. Interstitial lactate, pyruvate, glucose, and glycerol in the ileal wall were measured by using microdialysis. There were no differences in baseline values between the groups. Systemic blood pressure decreased initially but recovered and remained stable in both groups. In the control group, intestinal vascular resistance increased from 10.9 +/- 1.0 to 24.7 +/- 5.3 mm Hg x mL x min(-1) x kg(-1) (p <.05) at 8 hrs, and oxygen delivery decreased from 2.6 +/- 0.2 to 1.3 +/- 0.3 mL x min(-1) x kg(-1) (p <.05). Simultaneously, microdialysis lactate increased from 1.6 +/- 0.1 to 3.6 +/- 0.5 mmol/L (p <.05) with concomitant pyruvate increase and unchanged lactate/pyruvate ratio. Blood lactate increased and pH decreased. In the prostacyclin group at 8 hrs, intestinal vascular resistance of 6.9 +/- 0.8 mm Hg x mL x min(-1) x kg(-1) was lower and intestinal oxygen delivery of 3.2 +/- 0.3 was higher (p <.05) than in the control group at 8 hrs. Intestinal oxygen uptake of 0.54 +/- 0.10 mL x min(-1) x kg(-1) was higher than in the control group, in which oxygen uptake was 0.26 +/- 0.04 mL x min(-1) x kg(-1). Lactate, pyruvate, and pH were normalized at 8 hrs in the prostacyclin group. CONCLUSION: Low-dose prostacyclin has beneficial effects on small intestinal perfusion during endotoxemia in this experimental cat model.