Archive for February 10, 2017

Patients After Splenectomy: Old Risks and New Perspectives.

Chirurgia (Bucur). 2016 Sept-Oct;111(5):393-399. doi: 10.21614/chirurgia.111.5.393.

Dragomir M, Petrescu DGE, Manga GE, Călin GA, Vasilescu C; -.

Abstract

The risks that arise after splenectomy can be divided in infectious and non-infectious. The link between splenectomy and these hazards remains partially unknown.

Host defense against infection is altered after splenectomy and such individuals develop sepsis more easily and the infection has a fulminant course.

Splenectomy is also a potential risk factor for several vascular complications that result from partial or total obstruction of an arterial or venous blood vessel. Furthermore, pulmonary hypertensioncan be a severe and sometimes fatal complication following splenectomy.

Some authors also consider that malignancies, diabetes mellitus and acute pancreatitis are non-infectious complications after splenectomy.

The most feared complication for splenectomized patients remains sepsis. The pathophysiology of sepsis is still controversial.

Death in sepsis can occur due to either hyper-inflammation or immune paralysis. Multiple experimental evidences link cellular and viral microRNAs with sepsis.

We presume that miRNAs are also associated with the immunosuppression of the asplenic patients which leads to the high risk of deadly sepsis.

Studying the expression level of circulating miRNAs in asplenic patients could help us better understand the postsplenectomy immunosuppression and develop new diagnostic and therapeutic tools.

PDF

http://revistachirurgia.ro/pdfs/2016-5-393.pdf

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February 10, 2017 at 8:56 am

Posterior Reversible Encephalopathy Syndrome and Fatal Cryptococcal Meningitis After Immunosuppression in a Patient With Elderly Onset Inflammatory Bowel Disease.

ACG Case Rep J. 2016 Aug 3;3(4):e98. eCollection 2016.

Vasant DH1, Limdi JK1, Borg-Bartolo SP1, Bonington A2, George R3.

Author information

1Department of Gastroenterology, Pennine Acute Hospitals NHS Trust, United Kingdom; Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, United Kingdom.

2Department of Infectious Diseases, Pennine Acute Hospitals NHS Trust, United Kingdom; Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, United Kingdom.

3Department of Gastroenterology, Pennine Acute Hospitals NHS Trust, United Kingdom.

Abstract

Advanced age and associated comorbidities are-recognized predictors of life-threatening adverse outcomes, such as opportunistic infection following immunosuppressive therapy.

We describe the case of an elderly patient with stricturing colonic Crohn’s disease and significant clinical comorbidities, initially controlled with corticosteroid induction followed by infliximab, whose course was complicated by fatal disseminated cryptococcal infection and posterior reversible encephalopathy syndrome.

Our patient’s case highlights rare, but serious, complications of immunosuppression.

In applying modern treatment paradigms to the elderly, the clinician must consider the potential for more pronounced adverse effects in this potentially vulnerable group, maximizing benefit and minimizing harm.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5062660/pdf/CG-CGCR160009.pdf

February 10, 2017 at 8:54 am

Staphylococcus aureus bacteremia with iliac artery endarteritis in a patient receiving ustekinumab.

BMC Infect Dis. 2016 Oct 20;16(1):586.

Joost I1, Steinfurt J2, Meyer PT3, Kern WV4, Rieg S4.

Author information

1Division of Infectious Diseases, Department of Medicine II, University Medical Center Freiburg, Hugstetter Str. 55, Freiburg, 79106, Germany. insa.joost@uniklinik-freiburg.de

2Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Hugstetter Strasse 55, Freiburg, 79106, Germany.

3Department of Nuclear Medicine, University Medical Center Freiburg, Hugstetter Str. 55, Freiburg, 79106, Germany.

4Division of Infectious Diseases, Department of Medicine II, University Medical Center Freiburg, Hugstetter Str. 55, Freiburg, 79106, Germany.

Abstract

BACKGROUND:

Ustekinumab (Stelara®), a human monoclonal antibody targeting the p40-subunit of interleukin (IL)-12 and IL-23, is indicated for moderate to severe plaque psoriasis and psoriatic arthritis. In large multicenter, prospective trials assessing efficacy and safety of ustekinumab increased rates of severe infections have not been observed so far.

CASE PRESENTATION:

Here, we report the case of a 64-year old woman presenting with chills, pain and swelling of her right foot with dark maculae at the sole, and elevated inflammatory markers. She had received a third dose of ustekinumab due to psoriatic arthritis three days before admission. Blood cultures revealed growth of Staphylococcus aureus and imaging showed a thickening of the aortic wall ventral the bifurcation above the right internal iliac artery, resembling an acute bacterial endarteritis. Without the evidence of aneurysms and in absence of foreign bodies, the decision for conservative management was made. The patient received four weeks of antibiotic therapy with intravenous flucloxacillin, followed by an oral regime with levofloxacin and rifampicin for an additional four weeks. Inflammatory markers resolved promptly and the patient was discharged in good health.

CONCLUSION:

To our knowledge, this is the first report of a severe S. aureus infection in a patient receiving ustekinumab. Albeit ustekinumab is generally regarded as a safe drug, severe bacterial infections should always be included in the differential diagnosis of elevated inflammatory markers in patients receiving biologicals as these might present with nonspecific symptoms and fever might be absent. Any effort to detect deep-seated or metastatic infections should be made to prevent complications and to secure appropriate treatment. Although other risk factors for an invasive staphylococcal infection like psoriasis, recent corticosteroid injection, or prior hospitalisations were present, and therefore a directive causative link between the S. aureus bacteraemia and ustekinumab can not be drawn, we considered the reporting of this case worthwhile to alert clinicians as we believe that ongoing pharmacovigilance to detect increased risks for rare but severe infections beyond phase II and phase III trials in patients treated with biologicals is essential.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5072319/pdf/12879_2016_Article_1912.pdf

February 10, 2017 at 8:52 am

Infectious Complications After Liver Transplantation.

Gastroenterol Hepatol (N Y). 2015 Nov;11(11):741-53.

Hernandez Mdel P1, Martin P1, Simkins J1.

Author information

1Dr Hernandez is an assistant professor of medicine and Dr Martin is a professor of medicine in the Division of Hepatology at the University of Miami Miller School of Medicine in Miami, Florida. Dr Simkins is an assistant professor of medicine in the Division of Infectious Diseases at the University of Miami Miller School of Medicine.

Abstract

Orthotopic liver transplantation (OLT) is the standard of care for patients with decompensated cirrhosis and for patients with hepatocellular carcinoma.

More than 6000 liver transplants are performed annually in the United States. High patient and graft survival rates have been achieved in great part due to the availability of potent immunosuppressive agents.

Systemic immunosuppression has rendered the liver recipient susceptible to de novo infections as well as reactivation of preexisting latent infections. Infections occurring during the first month post-OLT are usually nosocomial, donor-derived, or the result of a perioperative complication.

The development of opportunistic infections (OIs) such as Aspergillus and the reactivation of latent infections such as Mycobacterium tuberculosis are more frequent 1 to 6 months posttransplant, when the net state of immunosuppression is the highest.

Immunosuppressive therapy is tapered 6 to 12 months post-OLT; therefore, infections occurring during that time period and afterward generally resemble those of the general population.

Screening strategies applied to determine the risk of an infection after transplantation and the use of prophylactic antimicrobial therapy have reduced the incidence of OIs after OLT.

This article will review the various causes of infection post-OLT and the therapies used to manage complications.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4849501/pdf/GH-11-741.pdf

February 10, 2017 at 8:49 am


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