<i>Aspergillus</i> mediastinitis following orthotopic heart transplantation: case report and review of the literature

Levin, Todd P; Suh, Byungse; Beltramo, D.; Samuel, Rafik

doi:10.1111/j.1399-3062.2004.00064.x

Cited by 26 publications

(20 citation statements)

References 9 publications

(12 reference statements)

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“…Fungal mediastinitis is very rare, is usually caused by C. albicans or Aspergillus species, and carries a particularly high mortality rate (8,23). As our patient had no underlying immunodeficiency or apparent skin disease, it is not clear exactly why the infection occurred.…”

Section: Case Reportmentioning

confidence: 75%

Sternal Wound Infection byTrichosporon inkinfollowing Cardiac Surgery

Davies

Logan

Johnson³

et al. 2006

J Clin Microbiol

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Wound infection following cardiac surgery is well described but is rarely due to fungal infection. We describe a case of sternal wound infection caused by Trichosporon inkin with a fatal outcome, in an immunocompetent patient following aortic root surgery. CASE REPORTA 71-year-old female with known severe aortic stenosis and a dilated aortic root was admitted for elective aortic root replacement surgery. She had a medical history of severe emphysema, leading to breathlessness at rest, and spirometry revealed a forced expiratory volume in 1 s of just 500 ml. The operation involved implantation of a porcine aortic root and a Dacron graft but was complicated by bleeding from the left coronary artery origin, necessitating saphenous vein grafting onto the left coronary. The surgery lasted for 8 h, and teicoplanin and gentamicin were administered as antibiotic prophylaxis prior to surgery, in accordance with local protocols.Postoperatively the patient was transferred to the intensive care unit, where she remained intubated and ventilated. A tracheostomy was performed on day 3, because a prolonged period of ventilation was anticipated. Further complications included acute renal failure, requiring continuous venous-venous hemofiltration. The patient also developed an intrinsic nodal cardiac rhythm and was paced via epicardial wires, inserted in theater and removed on day 7. On day 8 of her intensive care stay, she developed a ventilator-associated pneumonia, which was treated with cefuroxime and gentamicin, with some clinical response.A subsequent septic decline (accompanied by negative blood cultures) was treated with an empirical course of vancomycin and ceftazidime, but with no substantial change in the patient's condition and a continued inotrope requirement. On day 24 of admission, Candida albicans was isolated from a central venous catheter tip, urine, and respiratory secretions, and treatment with intravenous fluconazole (400 mg daily) was commenced. It was noted, on examination, that the patient had developed a left pleural rub, and a small left-sided pleural effusion was seen on a chest radiograph. Bloody material began to ooze from the lower portion of the sternal wound and previous epicardial pacing wire sites. The gram stain of this fluid revealed numerous pus cells with yeasts and fungal hyphae (Fig. 1). The wound dehisced, and one liter of pus drained spontaneously from the wound. There was associated sternal instability elicited upon examination. The patient was not considered a candidate for further surgical intervention, and her condition continued to deteriorate. She died 2 days later, 26 days postoperatively. No autopsy was performed.Subsequent to her death, blood cultures became positive after 2 days of incubation (Fig. 2) using the BacT/ALERT system (bioMérieux Inc., Durham, N.C.). The yeast isolated from both blood and sternal fluid was identified by the Mycology Reference Laboratory (HPA, Bristol, United Kingdom) as Trichosporon inkin by using AUXACOLOR (Bio-Rad, Marnes la Coquette, France), givin...

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Section: Case Reportmentioning

confidence: 75%

Sternal Wound Infection byTrichosporon inkinfollowing Cardiac Surgery

Davies

Logan

Johnson³

et al. 2006

J Clin Microbiol

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“…3 Aspergillus fungal mediastinitis has been reported after open-heart procedures, such as coronary artery bypass operations, but it is extremely rare after heart transplantation. 2,4 This could be because postsurgical mediastinitis usually occurs within 30 days, [4][5][6] but the significant waning of cellular immunity that makes a patient increasingly vulnerable to fungal infection occurs more than 30 days postoperatively.…”

Section: Discussionmentioning

confidence: 99%

“…1 Of all cardiothoracic procedures, orthotopic heart transplantation (OHT) is associated with the highest risk of mediastinitis (including bacterial and fungal), with infection rates of 2.5% to 6%. 3 A review of the literature reveals only 3 cases in which Aspergillus mediastinitis occurred after OHT; all 3 cases involved A. fumigatus. We describe what we believe to be the first case of Aspergillus calidoustus mediastinitis after OHT.…”

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confidence: 99%

Aspergillus Mediastinitis after Orthotopic Heart Transplantation: A Case Report

Ahmed¹,

Almanfi²,

Aftab³

et al. 2015

Texas Heart Institute Journal

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The U.S. Centers for Disease Control and Prevention defines Aspergillus mediastinitis as the presence of a positive culture result from a mediastinal sample, plus one of the following: 1) fever higher than 38 °C, or 2) chest pain or sternal instability with purulent effusion in the mediastinum or positive culture results from surgically obtained samples or blood.1 Of all cardiothoracic procedures, orthotopic heart transplantation (OHT) is associated with the highest risk of mediastinitis (including bacterial and fungal), with infection rates of 2.5% to 6%.3 A review of the literature reveals only 3 cases in which Aspergillus mediastinitis occurred after OHT; all 3 cases involved A. fumigatus. We describe what we believe to be the first case of Aspergillus calidoustus mediastinitis after OHT. Case ReportA 55-year-old woman was admitted for OHT. Her medical history was notable for ischemic cardiomyopathy, as well as for hypertension, dyslipidemia, coronary artery disease, myocardial infarction, ventricular tachycardia, paroxysmal atrial fibrillation, and chronic kidney disease. Her surgical history included implantation of a left ventricular assist device (LVAD), resection of a left ventricular aneurysm, and implantation of a biventricular defibrillator. She had no history of infectious sequelae with her LVAD. During the OHT procedure, the patient was coagulopathic and needed several units of different blood products. Her chest was temporarily closed at the end of the operation and was permanently closed 3 days later.Postoperatively, she had prolonged respiratory and renal failure that necessitated ventilator support, hemodialysis, and inotropic and vasopressor support. Despite the new heart, she also needed further circulatory support, including an intra-aortic balloon pump. Two weeks postoperatively, she underwent a tracheostomy. Five weeks postoperatively, she developed fever with an elevated white blood cell count. Physical examination revealed tenderness, erythema, and sternal wound drainage. A computed tomographic scan revealed a mediastinal fluid collection and thereby confirmed the diagnosis. Surgical drainage of the fluid and aggressive débridement of the infected sternum were performed. During débridement, we locally irrigated the infected tis-

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“…Por ello, la invasión tisular se observa casi exclusivamente en pacientes inmunodeprimidos, tales como los que sufren neutropenia prolongada primaria o secundaria a tratamientos citotóxicos, trasplante renal, hepático o cardiaco y médula ósea , dosis elevadas de corticoides, o enfermedad granulomatosa crónica (4)(5)(6)(7)(8).…”

Section: Discussionunclassified

Aneurisma micótico en cayado aórtico por Aspergillus fumigatus: aportación de un caso y revisión en la literatura

Fernández¹,

Moreno

2005

An. Med. Interna (Madrid)

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INTRODUCCIÓNLos hongos del género Aspergillus, que excepcionalmente son responsables de patología en el paciente inmunocompetente, son agentes patógenos importantes en pacientes inmunocomprometidos, de hecho las diferentes formas clínicas que puede adoptar la enfermedad pulmonar dependen del mecanismo patogénico de acción, el estado inmunológico y la respuesta del huésped. En los últimos años la incidencia de la aspergilosis pulmonar invasiva ha ido en aumento en relación con un aumento de factores de riesgo como son la neutropenia (< 500 y, sobre todo, < 100 células/10 6 /l), neutropenia prolongada, tratamiento con esteroides, enfermedad del injerto contra huésped en los trasplantes de médula ósea, el rechazo agudo y la enfermedad por CMV en los trasplantados de órgano sólido y el sida avanzado. En la aspergilosis pulmonar invasora hay desarrollo miceliar en el parénquina pulmonar, con o sin angioinvasión, causando bronconeumonía, neumonía lobar, necrotizante e infarto hemorrágico. La infección puede diseminarse por vía hematógena o extenderse a estructuras contiguas, como los grandes vasos, produciendo hemorragias en ocasiones fatales.Presentamos el caso de una rotura de un aneurisma micóti-co por Aspergillus spp. en un paciente con una aspergilosis pulmonar invasiva. [0212-7199 (2005)

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Aspergillus mediastinitis following orthotopic heart transplantation: case report and review of the literature

Cited by 26 publications

References 9 publications

Sternal Wound Infection byTrichosporon inkinfollowing Cardiac Surgery

Sternal Wound Infection byTrichosporon inkinfollowing Cardiac Surgery

Aspergillus Mediastinitis after Orthotopic Heart Transplantation: A Case Report

Aneurisma micótico en cayado aórtico por Aspergillus fumigatus: aportación de un caso y revisión en la literatura

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