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Biomedical subjects

S Kusne

Publications and source records attributed to S Kusne.

At least 37 records · Page 2Linked to original sources
PubMed2000

Human herpesvirus-6 in liver transplant recipients: role in pathogenesis of fungal infections, neurologic complications, and outcome.

BACKGROUND: The clinical impact and relevance of human herpesvirus-6 (HHV-6) infection in liver transplant recipients, has not been fully discerned. METHODS: A prospective study of 80 consecutive liver transplant recipients was performed using surveillance cultures for HHV-6 at weeks 2, 3, 4, and 6 after transplantation. Viral isolation was used for the detection of HHV-6. RESULTS: HHV-6 infection occurred in 39% (31 of 80) of the patients. Patients with HHV-6 infection were more likely to have hepatocellular carcinoma as underlying liver disease (P=.09). Mental status changes of unidentifiable etiology were significantly more likely to occur in patients with HHV-6 compared with those without (26%, 9 of 31 vs. 6%, 3 of 49, P=.008). HHV-6 infection was an independent predictor of invasive fungal infections (odds ratio 8.3, 95% confidence interval, 1.2-58.0, P=.03). A significant association between HHV-6 infection and CMV infection after transplantation, CMV recipient and donor serostatus, rejection, or fever of unknown origin, could not be documented. Mortality at last follow-up in patients with HHV-6 infection (29%, 9 of 31) was significantly greater than those without HHV-6 (6%, 3 of 49, P=.008). CONCLUSIONS: Central nervous system complications of unknown etiology after liver transplantation may be related to HHV-6 infection. HHV-6 viremia was an independently significant predictor of invasive fungal infections and was associated with late mortality in liver transplantation recipients.

Adult↗
PubMed1999

Cytomegalovirus PP65 antigenemia monitoring as a guide for preemptive therapy: a cost effective strategy for prevention of cytomegalovirus disease in adult liver transplant recipients.

BACKGROUND: The aim of the study was to assess the incidence of cytomegalovirus (CMV) infection and disease in adult liver transplant recipients, using routine preemptive therapy guided by the pp65 antigenemia test. METHODS: Antigenemia was monitored weekly after liver transplantation (OLTX) for the first 3 months, and once a month for another 3 months. CMV seronegative recipients were treated preemptively for the first positive antigenemia. Seropositive recipients were treated only when their antigenemia count reached a threshold of > or =100 positive cells per 200,000 leukocytes. RESULTS: A total of 144 patients were included between June 1994 and April 1995, of which 137 (95%) were primary OLTX. The percentage of positive antigenemia and CMV disease was 55 and 8%, respectively. Seventy-eight (54%) patients were protocol-monitored for the entire follow-up (group 1) and received appropriate preemptive therapy, although 66 (46%) patients had protocol violation by having missed blood samples or blood drawn at unscheduled times (group 2). Using Cox's proportional hazards model, patients with a first antigenemia count of >11 leukocytes had a significantly higher rate of CMV disease compared to patients with an antigenemia count < or =11 leukocytes (RR = 7.3, 95% confidence interval = 2.2 to 24.5). In a multivariate Cox regression analysis, adjustments were made to control for: group 1 versus group 2, use of OKT3, and serology risk categories. This analysis showed that the relative rate of CMV disease was still significantly higher among patients with antigenemia count >11 leukocytes (adjusted RR = 4.9, 95% confidence interval = 1.3 to 18.1). The estimated cost of preemptive therapy was less than that of prophylaxis with i.v. (14-day course) or oral (90-day course) ganciclovir. CONCLUSIONS: Preemptive therapy guided by pp65 antigenemia is a useful and cost effective strategy for prevention of CMV disease.

Adult↗
PubMed1999

Cytomegalovirus infection of the native ureter after liver-kidney transplantation.

We report a case of invasive cytomegalovirus (CMV) infection in the native ureter of a patient 7 years after liver-kidney transplantation. Previous reports of CMV ureteritis in transplant patients have involved only the allograft ureter, usually within 3 months of transplantation. The common characteristics of these patients, the possible risk factors, and the diagnostic findings of CMV ureteritis are discussed. Combined surgical and medical intervention are required for successful treatment.

Adult↗
PubMed1999

Prevention and treatment of cytomegalovirus infection in organ transplant recipients.

Cytomegalovirus (CMV) is the most common viral pathogen in organ transplant recipients. The patients at highest risk of developing CMV disease are seronegative recipients of seropositive donors, and seropositive recipients who receive antilymphocyte agents such as OKT3 and antithymocyte globulin (ATG) for induction or for rejection. There have been many trials of CMV prevention, but they are difficult to compare with one another because of variability in definitions and end points. Two modalities that have been used to prevent CMV disease are prophylaxis and preemptive therapy. In prophylaxis all patients are given an antiviral agent in order to prevent CMV disease, while in preemptive therapy (also called targeted prophylaxis) only patients who are identified as 'high risk' are selected for treatment. Selected trials of prophylaxis and preemptive therapy in solid-organ recipients are reviewed. The factors to be considered in using one modality or the other are side effects from antivirals, cost of monitoring and antivirals, efficacy of the two modalities, and potential emergence of drug resistance. Sensitive tests that have been used for early diagnosis and monitoring of CMV are antigenemia and the polymerase chain reaction (PCR). Antigen pp65 is a lower matrix protein and can be detected in peripheral blood leukocytes. The sensitivity and specificity are high and vary from 89% to 100% and 92% to 96%, respectively. Currently, many authors believe that the antigenemia test is more useful than the PCR test. The antigenemia test is useful for viral monitoring as a guide for preemptive therapy after organ transplantation. Persistence of high counts of antigenemia may indicate inadequate antiviral therapy or emergence of resistance. Recurrence of positive antigenemia after treatment of CMV disease can be a sign of relapse. Transplant patients who develop resistance to antiviral drugs are usually seronegative recipients who receive an organ from a seropositive donor and have several courses of antivirals for CMV disease. Ganciclovir is the most frequent antiviral agent used in transplant recipients and is usually well tolerated. Resistance to ganciclovir may occur and is usually secondary to virus mutation in the UL97 gene. The availability of sensitive diagnostic tests such as pp65 antigenemia has made the early diagnosis of CMV possible in organ transplant recipients. CMV is being treated much earlier now, and progression to disseminated disease is uncommon. Prudent use of antiviral drugs will hopefully limit the problem of drug resistance.

Antiviral Agents↗
PubMed1998

Epidemiology of legionella pneumonia and factors associated with legionella-related mortality at a tertiary care center.

Legionella pneumophila is an important pathogen that may cause nosocomial and community-acquired pneumonia in patients with normal or altered immunity. The epidemiology of 40 cases of legionella pneumonia in patients hospitalized between 1986 and 1994 was studied. Fourteen patients (35%) were solid organ transplant recipients. The calculated annual incidence of L. pneumophila infection was highest among lung transplant recipients (2.07 cases per 1,000 transplant-years). There was a trend toward reduced mortality rates and less severe disease among transplant patients vs. nontransplant patients: mortality rate, 36% vs. 54%; incidence of intubation, 50% vs. 69%; rate of concurrent infections, 29% vs. 38%; and overall rate of complications, 86% vs. 96%; respectively. In a multivariate analysis, factors independently associated with an increased mortality rate were nosocomial acquisition, need for intubation, formation of lung abscess or cavitation, and presence of pleural effusion. Thus, despite differing host immune responses, the most important prognostic factors affecting the outcome of legionellosis are nosocomial acquisition and the development of pulmonary complications.

Female↗
PubMed1998

Acute invasive sinusitis due to Trichoderma longibrachiatum in a liver and small bowel transplant recipient.

We describe a case of acute invasive sinusitis due to an unusual moniliaceous fungus, Trichoderma longibrachiatum Rifai 1969 (a member of the class Hyphomycetes), in a small bowel and liver transplant recipient treated with tacrolimus (FK-506) and prednisone. The patient was successfully treated with surgical debridements and amphotericin B followed by oral itraconazole.

Acute Disease↗
PubMed1997

Adenovirus hepatitis in the adult allograft liver.

BACKGROUND: Adenovirus hepatitis in the allograft liver is an uncommon condition hitherto recognized only in pediatric patients. We describe two adult cases. METHODS: Clinical information was obtained by reviewing the medical records. The diagnosis of adenoviral infection was made by immunohistochemistry or culture. RESULTS: Both patients had received recent antirejection treatment and presented with fever, hepatic dysfunction, and progressive leukopenia. One patient had some viral inclusions resembling those described in herpes simplex infections. Adenovirus was cultured from the liver in both cases and from the lung in one case. Both patients were treated by decreasing the immunosuppression and intravenous acyclovir, but died. CONCLUSIONS: Adenovirus infection should be considered when evaluating adult liver transplant patients with necrotizing lesions or microabscess formation at allograft biopsy. A review of the literature shows that most previously reported infections have led to graft loss or death, but occasional remissions of disease are also on record.

Adenoviridae Infections↗
PubMed1997

Brain abscess in solid organ transplant recipients receiving cyclosporine-based immunosuppression.

OBJECTIVE: To determine the incidence, clinical presentation, and outcome and confounding factors associated with the development of a brain abscess in solid organ transplant recipients. DESIGN: A 14-year retrospective survey. SETTING: A single, multiorgan, academic transplantation center. PATIENTS: A total of 2380 liver transplant recipients, 1650 kidney transplant recipients, and 598 heart, heart-lung, or lung transplant recipients of all ages (pediatric and adult) were included. All patients were given cyclosporine-based immunosuppression during this period. MAIN OUTCOME MEASURE: A brain abscess was determined to be present it there was histological and/or microbiological confirmation of a brain lesion seen by a computed tomographic scan. A brain abscess was considered suspicious if radiographic findings were seen in the clinical setting of neurologic symptoms and fever without histological or microbiological confirmation. RESULTS: A brain abscess developed in a total of 28 patients (0.61%) of the total study population. The frequency of brain abscess according to organ type was as follows: 0.63%, liver; 0.36%, kidney; and 1.17%, heart and heart-lung. The overall mortality was 86%. Complicating factors associated with fungal (Candida and Aspergillus sp) abscess formation included major subsequent operations, retransplantations, antirejection therapy, associated bacteremia or viremia, and multiorgan failure. The lung was the primary site of dissemination in 18 patients. Low-dose prophylactic amphotericin was ineffective in preventing a fungal brain abscess in 10 high-risk patients. Because of the ineffective therapy and the deadly nature of established fungal abscesses, full-dose antifungal therapy and reduced immunosuppression were warranted on identification of a high-risk clinical setting. Nonfungal abscesses (Nocardia and Toxoplasma sp) occurred in healthy graft recipients long after transplantation. The existing medical therapy is usually effective in these patients, provided that rapid tissue diagnosis is established. CONCLUSIONS: The epidemiological features of brain abscess formation after solid organ transplantation suggest 2 populations of patients exist that differ in timing, clinical setting, and response to therapy. For the chronically immunosuppressed outpatient, an established abscess should be empirically treated with sulfonamides until tissue diagnosis is confirmed. On the other hand, the acutely immunosuppressed posttransplant recipient, with defined risk factors, should receive full-dose therapy with amphotericin B and concomitantly lowered immunosuppression.

Adolescent↗
PubMed1997

Use of DNA amplification for diagnosis of cytomegalovirus enteritis after intestinal transplantation.

BACKGROUND & AIMS: Intestinal transplantation is a feasible therapy for patients with short-bowel syndrome. However, cytomegalovirus (CMV) enteritis can cause complications. The aim of this study was to investigate the value of polymerase chain reaction (PCR)-based detection methods for CMV in the management of patients with small bowel transplants. METHODS: Comparative evaluation of PCR with histopathology, shell-vial assay, and tube culture of intestinal biopsy specimens was used for the diagnosis of CMV enteritis in 21 patients. RESULTS: Ten patients experienced 21 episodes of CMV enteritis, diagnosed by histopathology, virology, or both. PCR had a sensitivity and specificity of 96% and 69%, respectively, compared with traditional methods, whereas the positive and negative predictive values were 35% and 99%, respectively. Three+ and 4+ signals corresponded to a specificity of 91% and positive predictive value of 59%, respectively. CMV was detected by PCR a median of 11 days (range, 0-32) earlier than other methods and lasted a median of 40 days (range, 21-80) in the 13 episodes, which became PCR-negative and in those patients who developed asymptomatic infection. In 8 episodes, CMV by PCR never became negative and was associated with a relapse of disease confirmed by other methods. CONCLUSIONS: PCR is a sensitive method for the early detection of CMV in intestinal biopsy specimens and can be used for preemptive therapy after intestinal transplantation.

Adult↗
PubMed1997

Posttransplant lymphoproliferative disease in primary Epstein-Barr virus infection after liver transplantation: the role of cytomegalovirus disease.

Epstein-Barr virus (EBV) plays a major role in the pathogenesis of posttransplant lymphoproliferative disease (PTLD). Patients who undergo primary EBV infection after transplantation are at greater risk of developing PTLD. In this retrospective study, the incidence of EBV infection and associated PTLD in 40 consecutive adult recipients who were seronegative for EBV at the time of liver transplantation were investigated, and risk factors for PTLD were analyzed. Of 37 patients with available timely posttransplant serum samples, 35 (95%) developed primary EBV infection. Of the 40 patients, 13 (33%) developed PTLD a median of 126 days (range, 48-776) after liver transplantation. The factor significantly associated with the development of PTLD was cytomegalovirus disease (relative risk, 7.3; 95% confidence interval, 2.36-22.6; P = .0006). Cytomegalovirus disease is a predictor for the development of PTLD in primary EBV infection after liver transplantation, and it may be a target for prophylactic intervention.

Adult↗
PubMed1997

Amphotericin B colloidal dispersion vs. amphotericin B as therapy for invasive aspergillosis.

To assess the efficacy and safety of amphotericin B colloidal dispersion (ABCD), 82 patients with proven or probable aspergillosis who were treated in clinical trials with ABCD were compared retrospectively with 261 patients with aspergillosis who were treated with amphotericin B at six cancer or transplant centers from January 1990 to June 1994. The groups were balanced in terms of underlying disease; ABCD recipients were younger and more likely to have preexisting renal insufficiency than were amphotericin B recipients (40.7% vs. 8.7%, respectively), and amphotericin B recipients were more likely to be neutropenic at baseline than were ABCD recipients (42.5% vs. 15.9%, respectively). Response rates (48.8%) and survival rates (50%) among ABCD-treated patients were higher than those (23.4% and 28.4%, respectively) among amphotericin B-treated patients (P < .001 for both comparisons). Renal dysfunction developed less frequently in ABCD recipients than in amphotericin B recipients (8.2% vs. 43.1%, respectively; P < .001). Multivariate analysis revealed that treatment group was the best predictor of response, mortality, and nephrotoxicity (ABCD: relative risk [RR] = 3.00, P = .002; RR = 0.35, P < .001; and RR = 0.13, P = .001; respectively). This retrospective study suggests that in the treatment of aspergillosis ABCD causes fewer nephrotoxic effects than amphotericin B and the efficacy of ABCD is at least comparable with that of amphotericin B.

Adolescent↗
PubMed1997

Leuconostoc bacteremia after liver transplantation: another cause of vancomycin resistant gram-positive infection.

Leuconostoc sp. are gram-positive bacteria intrinsically resistant to vancomycin, which can be confused with streptococci based on routine microbiological-characteristics. Infections secondary to Leuconostoc are uncommon, and usually affect patients with underlying diseases, prior use of vancomycin and those with central lines. The most common clinical presentation is fever secondary to a central line infection. We report the first case of Leuconostoc infection in a solid organ transplant recipient. The patient developed Leuconostoc bacteremia secondary to peritonitis, 60 d after undergoing liver transplantation. He was treated with clindamycin, gentamicin and underwent surgical debridement, but succumbed to other complications.

Adult↗
PubMed1997

Surgical infections in immunocompromised patients--prevention and treatment.

The care of immunocompromised patients is a challenge to all physicians. The variety of opportunistic infections that can develop in these patients underscores the importance of the immune response. The key to success in the prevention and management of infections in these patients lies in knowing what kind of infections to expect and instituting empirical treatment even before a specific diagnosis is made. With the advent of better preventive strategies, the use of prophylactic and preemptive therapies, and the introduction of new immunomodulators, successful outcomes in these interesting and challenging patients may be more easy to achieve in the future.

AIDS-Related Opportunistic Infections↗
PubMed1996

Candida albicans osteomyelitis in a liver transplant recipient: a case report and review of the literature.

A 51-year-old man developed fever and back pain 2 months after orthotopic liver transplantation for end-stage liver disease secondary to chronic hepatitis C infection. CT scan demonstrated destructive lesions in T12 suggestive of osteomyelitis. Aspiration biopsy of the vertebra revealed granulomatous inflammation and yeast forms; culture yielded Candida albicans. The patient improved with intravenous amphotericin B and 5-fluorocytosine and did not require surgical intervention. Candida osteomyelitis is a rare condition and to our knowledge it has not been reported before in liver transplant recipients. Awareness of this potential complication may shorten the delay in making the definitive diagnosis, which in turn may increase the likelihood of a response without sequela.

Candidiasis↗