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Postoperative aspergillosis

Postoperative aspergillosis. Alessandro C. Pasqualotto School of Medicine, The University of Manchester Wythenshawe Hospital, UK. Case report. Male, 70 year-old Elective aortic valve replacement. www.aspergillus.man.ac.uk/secure/casehistories/case048.htm. Case report. Male, 70 year-old

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Postoperative aspergillosis

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  1. Postoperative aspergillosis Alessandro C. PasqualottoSchool of Medicine, The University of ManchesterWythenshawe Hospital, UK

  2. Case report • Male, 70 year-old • Elective aortic valve replacement www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

  3. Case report • Male, 70 year-old • Elective aortic valve replacement • 4 months: fatigue and  physical endurance www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

  4. Case report • Male, 70 year-old • Elective aortic valve replacement • 4 months: fatigue and  physical endurance • 7 months: profuse diarrhoea www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

  5. Case report • Male, 70 year-old • Elective aortic valve replacement • 4 months: fatigue and  physical endurance • 7 months: profuse diarrhoea • One week later: chills + fever • 19,000 x 106 leukocytes. www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

  6. Case report • TEE: large aortic vegetation www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

  7. Case report • TEE: large aortic vegetation • Blood cultures: negative www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

  8. Case report • TEE: large aortic vegetation • Blood cultures: negative • Working diagnosis: viridans strep endocarditis www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

  9. Case report • TEE: large aortic vegetation • Blood cultures: negative • Working diagnosis: viridans strep endocarditis • Discharged on ceftriaxone and metronidazole www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

  10. Case report • TEE: large aortic vegetation • Blood cultures: negative • Working diagnosis: viridans strep endocarditis • Discharged on ceftriaxone and metronidazole • Readmitted for fever and CHF www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

  11. Case report • TEE: large aortic vegetation • Blood cultures: negative • Working diagnosis: viridans strep endocarditis • Discharged on ceftriaxone and metronidazole • Readmitted for fever and CHF • Vancomycin and doxycycline were added. www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

  12. Case report • After 2 days: hemiparesis and aphasia www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

  13. Case report • After 2 days: hemiparesis and aphasia • He died three days later www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

  14. Case report • After 2 days: hemiparesis and aphasia • He died three days later • Autopsy: • Massive cerebral haemorrhage • Embolus containing Aspergillusin the right middle cerebral artery www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

  15. Case report • After 2 days: hemiparesis and aphasia • He died three days later • Autopsy: • Massive cerebral haemorrhage • Embolus containing Aspergillus in the right middle cerebral artery • Endocarditis lesion: multiple hyphae www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

  16. Case report • After 2 days: hemiparesis and aphasia • He died three days later • Autopsy: • Massive cerebral haemorrhage • Embolus containing Aspergillus in the right middle cerebral artery • Endocarditis lesion: multiple hyphae • No other site of infection was found. www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

  17. Is that correct?

  18. Would someone have suspected aspergillosis?

  19. Aspergillosis • Aspergillus are ubiquitous • Soil, water and decaying vegetation

  20. Aspergillosis • Aspergillus are ubiquitous • Soil, water and decaying vegetation • Primarily acquired by inhalation

  21. Aspergillosis • Aspergillus are ubiquitous • Soil, water and decaying vegetation • Primarily acquired by inhalation • Nosocomial aspergillosis typically affects immunocompromised patients.

  22. That is not all the story …

  23. The spectrum of aspergillosis Frequency of aspergillosis www.aspergillus.man.ac.uk

  24. The spectrum of aspergillosis Frequency of aspergillosis Immune system www.aspergillus.man.ac.uk

  25. The spectrum of aspergillosis Frequency of aspergillosis Disfunction Immune system www.aspergillus.man.ac.uk

  26. Acute IA The spectrum of aspergillosis Frequency of aspergillosis Disfunction Immune system www.aspergillus.man.ac.uk

  27. Acute IA The spectrum of aspergillosis Subacute IA Frequency of aspergillosis Disfunction Immune system www.aspergillus.man.ac.uk

  28. Acute IA The spectrum of aspergillosis Subacute IA Frequency of aspergillosis Tracheobronchitis Fungus ball Chronic cavitary Chronic fibrosing Disfunction Normal . Immune system www.aspergillus.man.ac.uk

  29. Acute IA ABPA Allergic sinusitis The spectrum of aspergillosis Subacute IA Frequency of aspergillosis Tracheobronchitis Fungus ball Chronic cavitary Chronic fibrosing Disfunction Normal Hyper immune . Immune system www.aspergillus.man.ac.uk

  30. What about postoperative aspergillosis?

  31. Review of the world literature • Medline, LILACS and EMBASE

  32. Review of the world literature • Medline, LILACS and EMBASE • References were reviewed

  33. Review of the world literature • Medline, LILACS and EMBASE • References were reviewed • Conference abstracts (www.aspergillus.man.ac.uk)

  34. Review of the world literature • Medline, LILACS and EMBASE • References were reviewed • Conference abstracts (www.aspergillus.man.ac.uk) • Only cases of proven or probable aspergillosis were reviewed.

  35. Review of the world literature • Not included: • Primary cutaneous aspergillosis

  36. Review of the world literature • Not included: • Primary cutaneous aspergillosis Neonate Andresen J, et al. Acta Paediatr 2005; 94: 761-2.

  37. Review of the world literature • Not included: • Primary cutaneous aspergillosis Neonate Diabetes mellitus

  38. Review of the world literature • Not included: • Primary cutaneous aspergillosis Neonate Diabetes mellitus Burn patient www.aspergillus.man.ac.uk

  39. Review of the world literature • Not included: • Infections associated with intravascular devices

  40. Review of the world literature • Not included: • Infections associated with intravascular devices Neutropenia

  41. Review of the world literature • Not included: • Infections associated with intravascular devices Neutropenia HIV

  42. Literature review • More than 500 cases were included

  43. Literature review • More than 500 cases were included • Heart surgery: 188 • Dental surgery: > 100 • Ophthalmologic surgery: > 90 • Wound infections: 22 • Neurosurgery: 25 • Vascular prosthetic surgery: 22 • Orthopaedic surgery: 42 • Bronchial infections: 30 • Abdominal surgery: 10 • Mediastinitis: 11 • Breast surgery: 5 • Pleural aspergillosis: 1

  44. Endocarditis and aortitis • 124 cases

  45. Endocarditis and aortitis • 124 cases 40 other cases

  46. Endocarditis and aortitis • 124 cases • Male gender: 69.9%

  47. Endocarditis and aortitis • 124 cases • Male gender: 69.9% • Median age: 43.5 years-old (0.8 to 71)

  48. Endocarditis and aortitis • 124 cases • Male gender: 69.9% • Median age: 43.5 years-old (0.8 to 71) • Main valves: • Aortic: involved in 60.5% • Mitral: 30.6%

  49. Endocarditis and aortitis • 124 cases • Male gender: 69.9% • Median age: 43.5 years-old (0.8 to 71) • Main valves: • Aortic: involved in 60.5% • Mitral: 30.6% • Median 2.7 months after surgery (<1 to > 12).

  50. Key features • Absence of immunosuppression

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