肝移植患者术后合并侵袭性真菌感染诊疗进展

正肝移植是目前临床用于严重肝脏疾病治疗最有效的方法,但是由于术后免疫抑制剂及有创操作应用,使得伴随而来的术后感染亦非常常见,其中真菌感染的比率占到7%～42%,且由侵袭性念珠菌、侵袭性曲霉菌感染的死亡率分别可达71%和74%～92%~[1-2]。最新的一项关于肝移植后存活率的临床分析中显示侵袭性真菌感染是影响移植后患者存活的风险因素(OR=5.14,P0.001)~[3]。这使得活体肝移植手术的成功     

首诊于眼科的侵袭性真菌性鼻窦炎2例报告

我院曾收治首诊于眼科的侵袭性真菌性鼻窦炎患者2例。现报告如下。 例1：男,60岁。入院前15d因左眼结膜充血于当地医院诊断为急性结膜炎,氧氟沙星眼水治疗无明显好转。入院前4d前突然出现左眼视力下降、眼球突出并固定、体温升高,当地医院给予静滴青霉素治疗,无明显好转。     

鼻内镜手术治疗非侵袭性真菌性上颌窦炎的疗效

真菌性上颌窦炎根据菌群致病类型不同,分为非侵袭性真菌性上颌窦炎和侵袭性真菌性上颌窦炎两大类。非侵袭性真菌性上颌窦炎只局限于上颌窦腔内,不侵犯黏膜和骨壁,造成毗邻组织损伤〔1〕。临床多表现为鼻塞、流脓涕,涕有恶臭味等。鼻内窥镜及监视系统是一项近年来广泛应用于鼻科疾病治疗的技术,因其可以伸入狭窄的鼻腔和鼻道内,对鼻腔鼻窦进行精细治疗,故创伤小,预后良好〔2〕。本文就非侵袭性真菌性上颌窦炎患者进行分组对比治疗,分析鼻内镜手术疗效。     

鼻内窥镜下手术治疗霉菌性鼻窦炎疗效分析

目的评价经鼻内窥镜手术治疗真菌性鼻窦炎的疗效。方法对48例霉菌性鼻窦炎患者的治疗进行回顾性分析。所有患者采用以鼻内窥镜手术为主的治疗,辅以术后常规鼻内窥镜随访换药,随访时间以6-12月。结果 48例均I期获得治愈。结论鼻风镜手术是治疗霉菌性鼻窦炎的有效手段,术后随访换药是保证手术成功的重要环节。     

肝移植相关心血管并发症的发生与防治

肝移植是治疗急性肝衰竭、失代偿期肝硬化及肝细胞癌等终末期肝病的有效方法。近年,随着患者对医疗技术水平的认识和对术后生活质量要求的提高,肝移植已逐渐成为临床常见手术。从肝移植术前、术中及术后3个方面,阐述肝移植相关心血管并发症发生的原因和防治方法,旨在更好的认识和指导肝移植临床工作。     

肝移植术后早期急性肺水肿14例临床相关因素分析

目的 探讨肝移植术后早期急性肺水肿的临床相关因素,为临床合理处理提供线索。方法观察我院行肝移植术后急性肺水肿14例患者的术前终末期肝病模型（MELD）评分、手术前后肾功能（尿量、血肌酐）的变化情况;记录移植术中及术后前3d总入量、总出量和液体平衡量。结果肝移植术后急性肺水肿患者（14例）术前MELD评分较非肺水肿组（127例）显著增高（P〈0．01）,且术后死亡率明显上升（P〈0．01）;急性肺水肿患者术前存在肾功能不全,术后血肌酐、尿量延迟恢复;术中、术后液体正平衡显著增加,与非肺水肿组差异均有统计学意义（P〈0．01）。结论肝移植术后早期急性肺水肿与术前高MELD分值、术前肾功能障碍、术后肾功能延迟恢复及术中大量输液、术后限液不足密切相关,术中、术后严格控制出入量平衡,尽快恢复患者肾功能及相关重要脏器支持是防止肝移植早期急性肺水肿的有效措施。     

背驮式肝移植治疗急性肝衰竭15例

目的探讨肝移植治疗急性肝衰竭（ALF）的临床疗效，总结移植前处理、手术时机的选择以及术中关键技术应用的经验。方法回顾性分析了1999年9月2006年2月采用背驮式肝移植治疗15例ALF患者的临床资料。结果患者均获随访，术后1年生存率87％（13／15）。其中2例急性肝衰竭型威尔逊氏病患者术后角膜K—F环消失，血清铜蓝蛋白恢复正常。1例术后第11天死于多系统器官功能衰竭，1例患者术后第6天死于严重肺部感染，其余11例HBsAg转阴。结论肝移植是治疗ALF的有效方法，能提高ALF患者的生存率；年龄不应作为ALF患者肝移植的禁忌证；充分的术前准备和恰当的移植时机选择以及术中关键技术的使用是提高术后生存率的关键。     

原发性胆汁性胆管炎肝移植术后预后研究现状与挑战

原发性胆汁性胆管炎(PBC)是一种病因尚不明确的慢性胆汁淤积性肝病。熊去氧胆酸、奥贝胆酸等药物治疗不佳的患者最终发展为肝硬化,甚至肝衰竭。目前,肝移植是治疗PBC的唯一有效手段。主要阐述了PBC患者进行肝移植的概况、肝移植术后生存期、并发症、PBC复发以及肝移植治疗前景及挑战,为PBC移植术后的临床转归及治疗提供参考。     

可调节探钩在高血压患者真菌性上颌窦炎手术中的应用

目的 探讨鼻内镜下应用可调节探钩治疗高血压患者真菌性上颌窦炎的疗效.方法 随机将63例非侵袭性真菌性上颌窦炎高血压患者分为两组：A组32例,采用鼻内镜下中鼻道径路结合术中应用可调节探钩径路治疗;B组31例,采用鼻内镜下经中、下鼻道联合径路治疗.术后随访半年,比较两组疗效,同时观察患者术后舒适程度及血压波动情况.结果 A组治愈31例,治愈率96.9％;B组治愈29例,治愈率93.5％.A组术后反应轻,不适程度小,血压波动小;B组术后反应重,疼痛显著,血压波动大,两组比较差异有统计学意义（P＜0.05）.结论 相比较经鼻内镜下中、下鼻道联合径路,鼻内镜下中鼻道径路结合术中应用可调节探钩治疗高血压患者真菌性上颌窦炎具有血压波动小、疼痛轻、出血少、创伤小、恢复快的优点,符合微创理念,值得临床推广.     

肝移植术后并发症的影像学评估

肝移植是治疗终末期慢性肝脏疾病和急性肝衰竭的有效方法。随着外科技术、器官保存技术及药物治疗的迅速发展,术后患者的生存率不断提高。然而,术后并发症仍然是影响移植术后发病率及死亡率的主要因素。由于临床及实验室检查缺乏特异性,术后各类并发症的诊断相当困难,影像学技术的应用有效解决了这一问题。总结了肝移植术后常见并发症包括血管源性并发症、胆系并发症、肝实质病变及术后感染等的影像学表现,指出影像学检查具有极大优势,可多方位评估疾病的进展情况。     

Colonic mucormycosis presented with ischemic colitis in a liver transplant recipient

Mucormycosis is an uncommon opportunistic fungal infection with high mortality in liver transplant recipients. Mucormycosis of the gastrointestinal tract can manifest with features similar to ischemic colitis. Typically signs and symptoms of non-gangrenous ischemic colitis resolve spontaneously within 24-48 h. On the other hand, the clinical course of the mucormycosis is commonly fulminant. We encountered a case of invasive fungal colitis presenting with abdominal pain and hematochezia in a liver transplant recipient. Endoscopic examination showed multiple shallow ulcerations and edema with mucosal friabilities on the sigmoid and distal descending colon, which was consistent with ischemic colitis. However, the histological examination obtained from endoscopic biopsies showed fungal hyphae withsurrounding inflammatory cells and mucosal necrosis. The patient was successfully managed with antifungal agent without surgical treatment. Thus, early diagnosis and treatment is essential for improving the prognosis of invasive fungal infection after liver transplantation.     

儿童肝豆状核变性急性肝衰竭的诊断与治疗

急性肝衰竭(ALF)是儿童肝豆状核变性(WD)一种特殊的临床表现形式，相对罕见但极为严重；其特征为进行性加重的黄疸和显著的凝血功能障碍，伴急性血管内溶血，易并发肝性脑病、急性肾衰竭等严重并发症，一旦起病，进展迅速，病死率高。目前，表现为ALF的WD缺乏单一的快速诊断指标，早期诊断困难。既往多认为肝移植是其唯一治疗方法，现发现非肝移植的内科治疗可使部分儿童WD-ALF获得自体肝缓解和恢复。     

ALLERGIC FUNGAL SINUSITIS PRESENTING AS A PARANASAL SINUS TUMOUR

Allergic fungal rhinosinusitis is a rare complication of atopic upper airways disease which may present initially as an expansive tumour of the paranasal sinuses. This reported case was caused by the rare fungal pathogen Bipolaris hawiiensis and illustrates typical clinical and laboratory features of this disorder. Although the optimum management of allergic fungal sinusitis is controversial, combined therapy with surgical clearance, antifungal agents and corticosteroids produced a favourable outcome.     

Fungal rhinosinusitis: Diagnosis and therapy

Fungal rhinosinusitis presents in five clinicopathologic forms, each with distinct diagnostic criteria, treatment, and prognosis. The invasive forms are acute fulminant, chronic, and granulomatous ("indolent") invasive fungal sinusitis. The noninvasive forms are fungal ball ("sinus mycetoma") and allergic fungal sinusitis (AFS). AFS is the most common form of fungal rhinosinusitis. Patients with AFS are atopic to aeroallergens including the involved fungal organism, immunocompetent, have nasal polyps and chronic allergic rhinosinusitis, often produce nasal casts, and may occasionally present with proptosis from orbital extension of disease. Sinus CT shows sinus mucosal hypertrophy and often hyperattenuation of sinus contents. Diagnosis is made from surgical histopathology with or without an associated positive surgical sinus fungal culture. The histopathology shows extramucosal allergic mucin that stains positive for scattered fungal hyphae and eosinophilic-lymphocytic sinus mucosal inflammation. Bipolaris spicifera is the most common fungus cultured. The immunopathology of AFS has been shown to be analogous to allergic bronchopulmonary aspergillosis. Treatment requires surgery and aggressive postoperative medical management with close follow-up. Medical treatment includes allergy medications, allergen immunotherapy, and in many cases the addition of oral corticosteroids. Although medical management clearly improves patient outcomes, more studies are needed because AFS recurrence rates remain high.     

Drug Induced Liver Injury: Review with a Focus on Genetic Factors,Tissue Diagnosis,and Treatment Options

Drug-induced liver injury (DILI) is a rare but potentially life threatening adverse drug reaction. DILI may mimic any morphologic characteristic of acute or chronic liver disease, and the histopathologic features of DILI may be indistinguishable from those of other causes of liver injury, such as acute viral hepatitis. In this review article, we provide an update on causative agents, clinical features, pathogenesis, diagnosis modalities, and outcomes of DILI. In addition, we review results of recently reported genetic studies and updates on pharmacological and invasive treatments.     

Two children with differing outcomes after treatment for pulmonary tuberculosis diagnosed after allogeneic hematopoietic stem cell transplantation

J.W. Lee, H.‐J. Kwon, P.‐S. Jang, N.‐G. Chung, B. Cho, D.‐C. Jeong, J.‐H. Kang, H.‐K. Kim. Two children with differing outcomes after treatment for pulmonary tuberculosis diagnosed after allogeneic hematopoietic stem cell transplantation.
Transpl Infect Dis 2011: 13: 520–523. All rights reserved. Abstract: Tuberculosis (TB) is a rare infectious complication after hematopoietic stem cell transplantation (HSCT), but may be more significant in areas where the disease is endemic. Here, we present the clinical course of 2 children with acute lymphoblastic leukemia who were diagnosed with pulmonary TB after allogeneic HSCT. Both patients were treated for either probable or possible invasive fungal infection, as well as TB. One patient, diagnosed with TB 3 months after HSCT, showed remittent fever and symptoms that progressed to acute respiratory distress syndrome and death, despite 3 modifications to the anti‐TB regimen. In contrast, another patient who was diagnosed with TB 8 months after transplantation, responded well to anti‐TB medication and completed 1 year of treatment with resolution of lung lesions. Co‐morbid opportunistic infections, profound host immunosuppression early after transplantation, and potential risk of multi‐drug resistant‐TB may act as major barriers to effective treatment of TB after HSCT despite appropriate anti‐TB medication.     

Fungal infections following liver transplantation

With increasing morbidity and mortality from chronic liver disease and acute liver failure, the need for liver transplantation is on the rise. Most of these patients are extremely vulnerable to infections as they are immune-compromised and have other chronic co-morbid conditions. Despite the recent advances in practice and improvement in diagnostic surveillance and treatment modalities, a major portion of these patients continue to be affected by post-transplant infections. Of these, fungal infections are particularly notorious given their vague and insidious onset and are very challenging to diagnose. This mini-review aims to discuss the incidence of fungal infections following liver transplantation, the different fungi involved, the risk factors, which predispose these patients to such infections, associated diagnostic challenges, and the role of prophylaxis. The population at risk is increasingly old and frail, suffering from various other co-morbid conditions, and needs special attention. To improve care and to decrease the burden of such infections, we need to identify the at-risk population with more robust clinical and diagnostic parameters. A more robust global consensus and stringent guidelines are needed to fight against resistant microbes and maintain the longevity of current antimicrobial therapies.     

Cutaneous mucormycosis

Mucormycosis is an aggressive invasive fungal infection that occurs rarely in immunocompetent but frequently in immunocompromised patients. We present a case of a 68‐year‐old patient with cutaneous mucormycosis due to Rhizopus pusillus. He was initially hospitalized for invasive pulmonary aspergillosis and diabetes mellitus secondary to acute graft‐versus‐host treatment with glucocorticoids after allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia. Treatment with liposomal amphotericin B and posaconazole was initiated but the patient developed septic shock with multiple organ failure and died 5 days later. The risk factors, clinical presentation, treatment, and prognosis of cutaneous mucormycosis in hematopoietic stem cell and solid organ transplant patients are discussed.     

Graft-versus-host disease after liver transplantation complicated by systemic aspergillosis with pancarditis.

Graft-versus-host disease after liver transplantation complicated by systemic aspergillosis with pancarditis. Can J Gastroenterol 2000;14(7):637-640. Acute graft-versus-host disease (GVHD) is a common complication after bone marrow transplantation, with characteristic rash and diarrhea being the most common features. After liver transplantation, however, this phenomenon is very rare. Most transplant patients are on a variety of medications, including immunosuppressants; therefore, the differential diagnosis of skin rash or diarrhea is broad. A 37-year-old man who underwent liver transplantation for primary biliary cirrhosis, and developed a rash and watery diarrhea, is presented. Skin and colonic biopsies confirmed acute GVHD. A pulse of intravenous steroids was given. The skin rash improved, but he developed pancytopenia. His course was complicated by central line infection, jugular and subclavian vein thrombosis, pseudomembranous colitis, recurrent bacteremia, cholestasis on total parenteral nutrition and cytomegalovirus infection. After the onset of pleuritic chest pain and clinical sepsis, spiral computed tomography scan of his chest and abdomen revealed septic infarcts in multiple organs. Despite empirical treatment with amphotericin B, he died of multiorgan dysfunction syndrome within 72 h. Autopsy revealed systemic aspergillosis with pancarditis, endocardial vegetations, and septic pulmonary, splenic, hepatic and renal infarcts. The pathogenesis and experience with this rare, but often fatal, complication of liver transplantation are reviewed. In contrast to GVHD after bone marrow transplantation, pancytopenia is common and liver dysfunction is rare. One should have a high level of suspicion in the liver transplant recipient presenting with rash and/or diarrhea.