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.     

Paucisymptomatic Dermoid Cyst with Fatal Outcome

Dermoid cysts of the central nervous system can cause devastating complications because of the mass effect of meningitis due to sinus tract. We report the case of a 5‐month‐old girl who presented with a crusted lesion of the occipital region of the scalp. Clinical examination noted skin abnormalities suggestive of occult dysraphism. Magnetic resonance imaging (MRI) was recommended, however, 40 days after this evaluation, and before the MRI could be performed, the girl presented with neurologic complications. Unfortunately, the diagnosis of dermoid cyst was made after the onset of severe complications that led to her death. The findings in this case emphasize the importance of more prompt MRI evaluation, particularly in cases where cranial or spinal dysraphism is suspected to have any connection to the skin as a pit or tract. Should we perform an urgent MRI for any cutaneous sign of dysraphism to avoid a dramatic evolution?     

Is peripheral alcohol injection of value in the treatment of trigeminal neuralgia? An analysis of 100 cases

This retrospective study assessed the effectiveness and complications of peripheral alcohol injections in the management of trigeminal neuralgia (TN). 100 patients were analyzed who received 250 peripheral alcohol injections from June 2004 to January 2010. The duration of effect of alcohol blocks, the effect of repeated administration, and complications associated with alcohol injections were examined. The distal injection technique was applied. The branch of the nerve was identified and confirmed. After carefully anesthetizing the nerve with local anesthesia, 1-1.5 ml of absolute alcohol was injected depending on the nerve involved. Pain relief lasted for a mean of 14.13 ± 8.66 months. There was a fall in the duration of effect with subsequent injections. No serious complications were reported. Only 3% patients presented with non-neuralgic pain, swelling, burning sensation, trismus, dysesthesia, soreness, infection and the expected loss of sensation along the branch involved in TN. The combination of efficacy and reduced morbidity makes this procedure preferable for the treatment of TN. Alcohol injections are useful in those who are refractory to drug therapy, the elderly, medically compromised patients, unwilling to undergo neurosurgical procedures and in whom surgery is delayed for any reason.     

Comparison of C-reactive protein and high-sensitivity C-reactive protein levels in patients on hemodialysis

Chronic inflammation is highly prevalent in patients on hemodialysis (HD), as evidenced by increased levels of C-reactive protein (CRP). We compared CRP to high-sensitivity C-reactive protein (hs-CRP) to determine whether it has any clinical implications and prognostic significance in terms of mortality. CRP was measured using a standard immunoturbidometric assay on the COBAS? INTEGRA system and hs-CRP was measured using the Dade Behring on the Konelab Nephelometer in 50 patients on HD. CRP (≥6 mg/L) and hs-CRP (≥3 mg/L) levels were elevated in 30% and 54% of the patients, respectively. A significant correlation was noted between hs-CRP and CRP levels (r = 0.98, P <0.001). Deming regression analysis showed that the slope was near one (r = 0.90; 0.83-0.94) and that the intercept was small. Multivariate regression confirmed that age above 40 years (RR = 3.69, P = 0.027) and duration on HD greater than five years (RR = 3.71, P = 0.028) remained significant independent predictors of serum hs-CRP. Thirteen patients died during follow-up (26%). Multivariate Cox regression demonstrated that hs-CRP (RR = 1.062, P = 0.03) and CRP levels (RR = 1.057, P = 0.009) and age (RR = 1.078, P = 0.001) were the most powerful predictors of mortality. The CRP standard assay presents a reasonable alternative to the hs-CRP assay in patients on HD. The advantages of the CRP standard assay are its online and real-time availability as well as lower costs, particularly in developing countries.