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IntroductionAntifungal agents are routinely used in the post-transplant setting for both prophylaxis and treatment of presumed and proven fungal infections. Micafungin is an echinocandin-class antifungal with broad antifungal cover and favorable side effect profile but, notably, it has no activity against molds of the order Mucorales.Presentation of caseA 47-year-old woman underwent multivisceral transplantation for intestinal failure-associated liver disease. She had a prolonged post-operative recovery complicated by invasive candidiasis and developed an intolerance to liposomal amphotericin B. In view of her immunosuppression, she was commenced on micafungin as prophylaxis to prevent invasive fungal infection. However, she developed acute graft versus host disease with bone marrow failure complicated by disseminated mucormycosis which was only diagnosed post mortem.DiscussionNon-Aspergillus breakthrough mold infections with micafungin therapy are rare with only eight other cases having been described in the literature. Breakthrough infections have occurred within one week of starting micafungin. Diagnosis is problematic and requires a high degree of clinical suspicion and microscopic/histological examination of an involved site. The management of these aggressive infections involves extensive debridement and appropriate antifungal cover.ConclusionA high level of suspicion of invasive fungal infection is required at all times in immunosuppressed patients, even those receiving antifungal prophylaxis. Early biopsy is required. Even with early recognition and aggressive treatment of these infections, prognosis is poor.

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Descriptions of passenger lymphocyte syndrome (PLS), immune cytopenias and transplant-associated thrombotic microangiopathy (TA-TMA) after intestine-containing transplants remain scarce. We describe our centre's experience of these complications from 2007 to 2019. Ninety-six patients received 103 transplants. PLS occurred in 9 (9%) patients (median 12 days post-transplant); all due to ABO antibodies. There were 31 minor ABO mismatch transplants. No patient required change in immunosuppression. Immune cytopenias (excluding PLS) occurred in six patients at an incidence of 1Á7/100 patient years; three immune haemolysis, one immune thrombocytopenia, one acquired Glanzmann's and one immune neutropenia; 50% occurred with other cytopenias. All cases eventually responded to treatment, with a median of four treatments (range 1-8) and 5/6 were treated with rituximab. One patient with immune haemolysis required bortezomib. Complications were common in patients with immune cytopenias; 4/6 with infection needing intravenous antibiotics and 3/6 with venous thromboembolism. In 3/6 cases, a secondary cause for the immune cytopenia was evident. Switching from tacrolimus to ciclosporin was not necessary. There were five cases of transplant-associated thrombotic microangiopathy (TA-TMA; 1Á5/100 patient years) requiring calcineurin inhibitor withdrawal; two cases associated with acute rejection. Two cases were managed with plasma exchange, one with plasma infusions and one with eculizumab. Further research in this patient group is required.

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Introduction Small bowel transplantation (SBT) was first performed in the UK in Cambridge in 1991. Recipients mow undergo small bowel (SBT), liver and small bowel (LSBT), modified multivisceral (MMVTsmall bowel, stomach, pancreas, no liver) and multivisceral (MVTintestine, stomach, pancreas and liver) transplantation. Cambridge is the only UK centre offering MVT in adults. The main indications for referral to a transplant centre are: 1. Irreversible intestinal failure plus life threatening complications of parenteral nutrition (PN). 2. Extensive surgery requiring partial or complete evisceration. Methods Prospective data was collected from all patients who underwent intestinal and multivisceral transplantation at Addenbrooke's Hospital between 2003 and 2013. All patients are discussed and indications for transplantation agreed prior to listing at NASIT (National Adult Small Intestinal Transplant forum). Results 47 transplants were performed on 43 patients; 4 procedures (9%) were re-transplantation for a primary non-functioning graft (2/4) or acute rejection (2/4). The indications for transplant are presented below: Sixteen transplants were performed in 2013-MVT (57%), SBT (31%), LSB (6%) and MMVT (6%). 50% of these were due to short bowel-arterial ischaemia (50%), Crohn's (26%), venous ischaemia (12%) and other short bowel (12%). Colon is now routinely included in the graft to aid fluid balance and does not preclude endoscopic surveillance for rejection. Conclusion The number of small bowel and multivisceral transplants performed over the last 10 years has increased, and more than doubled in 2013. Short bowel remains the commonest indication for transplantation. Historically this was mainly due to Crohn's disease however in 2013, it was mainly due to ischaemia; this trend was reflected worldwide. In our cohort, an increase in acute arterial thromboses causing coeliac/mesenteric ischaemia resulted in 3 recipients being listed urgently for MVT. There has also been an increase in the number of patients referred with portal vein thromboses extending into the superior mesenteric vein, precluding liver transplant alone. Disclosure of Interest None Declared.