The study was designed to identify a subset of heart transplant (HT) recipients who could benefit from the administration of targeted antifungal prophylaxis and to evaluate the efficacy of oral itraconazole as the preventive drug. We have analyzed the risk factors for invasive aspergillosis (IA) in our entire population of HT recipients (1988)(1989)(1990)(1991)(1992)(1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002) and also the role of oral itraconazole prophylaxis that was provided to all patients since 1995 [400 mg q.d. of itraconazole oral (PO) for 3-6 months]. There were 24 cases of IA. Our main results indicate that the independent risk factors for IA after heart transplantation are: re-operation (RR 5.8; 95% CI 1.8-18, p = = 0.002), cytomegalovirus (CMV) disease (RR 5.2; 95% CI 2-13.9, p = = 0.001), post-transplant hemodialysis (RR 4.9; 95% CI 1.2-18, p = = 0.02), and the existence of an episode of IA in the HT program 2 months before or after the transplantation date (RR 4.6; 95% CI 1.5-14.4, p = = 0.007). Itraconazole prophylaxis showed an independent protective value against developing IA (RR 0.2; 95% CI 0.07-0.9, p = = 0.03) and also determined a significantly prolonged 1-year survival (RR 0.5; 95% CI 0.3-0.8, p = = 0.01). We believe that antifungal prophylaxis in heart transplant patients should be offered at least to patients with one or more of these predisposing conditions.
Ocular tuberculosis has traditionally been considered uncommon or anecdotal. Imprecise and variable diagnostic criteria have contributed to the confusion surrounding this topic. The increase in extrapulmonary manifestations of tuberculosis during the AIDS era established the need for a prospective study of ocular involvement in patients with all types of tuberculosis using well-defined criteria. During a 15-month period, 300 cases had culture-proven tuberculosis at our institution. We randomly selected 100 for systematic ophthalmologic evaluation. Our criteria for ocular tuberculosis were divided as follows: certainty (isolation of Mycobacterium tuberculosis from ocular specimens), probability (patients with isolation of M. tuberculosis from extraocular samples, with ocular lesions not attributable to other causes that respond to anti-tuberculous treatment), and possibility (same as probability but follow-up impossible). Ocular tuberculosis was present in 18 patients (18%) of which 10 patients fulfilled probability and 8 patients fulfilled possibility criteria. Eleven of 18 patients had HIV infection. In 11 patients, ocular involvement was asymptomatic. Almost all patients (17/18) had choroiditis, and other ocular lesions included papillitis, retinitis, vitritis, vasculitis, dacryoadenitis, and scleritis. Multivariate analysis showed as risk factors independently predicting ocular involvement in patients with ocular tuberculosis the presence of miliary disease (odd ratio 43.92, p = 0.002), ocular symptoms (odds ratio 6.35, p = 0.0143), and decreased visual acuity (odds ratio 0.04, p = 0.012). We observed an unexpectedly high (18%) incidence of ocular involvement, frequently asymptomatic, in patients with tuberculosis. Miliary disease is a clear predisposing factor in both HIV-infected and noninfected populations. Ocular examination should be routinely considered in patients with proven or suspected tuberculosis.
Age at transplantation>45 years, induction therapy use, and high sunshine zone were risk factors for both SCC and BCC. Different immunosuppressive agents have different risks of nonmelanoma skin cancer, as AZA increases the risk of SCC and MMF is a protective factor. The relative risk of BCC was not affected by any immunosuppressor.
BSIs have decreased in HT recipients, but still contribute to mortality, mainly if related to pneumonia or polymicrobial infections. Reduction of early postoperative complications and viral infections are amenable goals that may further reduce BSI in this population.
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