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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 Alessandro C. PasqualottoSchool of Medicine, The University of ManchesterWythenshawe 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 • Elective aortic valve replacement • 4 months: fatigue and physical endurance www.aspergillus.man.ac.uk/secure/casehistories/case048.htm
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
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
Case report • TEE: large aortic vegetation www.aspergillus.man.ac.uk/secure/casehistories/case048.htm
Case report • TEE: large aortic vegetation • Blood cultures: negative www.aspergillus.man.ac.uk/secure/casehistories/case048.htm
Case report • TEE: large aortic vegetation • Blood cultures: negative • Working diagnosis: viridans strep endocarditis www.aspergillus.man.ac.uk/secure/casehistories/case048.htm
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
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
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
Case report • After 2 days: hemiparesis and aphasia www.aspergillus.man.ac.uk/secure/casehistories/case048.htm
Case report • After 2 days: hemiparesis and aphasia • He died three days later www.aspergillus.man.ac.uk/secure/casehistories/case048.htm
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
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
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
Aspergillosis • Aspergillus are ubiquitous • Soil, water and decaying vegetation
Aspergillosis • Aspergillus are ubiquitous • Soil, water and decaying vegetation • Primarily acquired by inhalation
Aspergillosis • Aspergillus are ubiquitous • Soil, water and decaying vegetation • Primarily acquired by inhalation • Nosocomial aspergillosis typically affects immunocompromised patients.
The spectrum of aspergillosis Frequency of aspergillosis www.aspergillus.man.ac.uk
The spectrum of aspergillosis Frequency of aspergillosis Immune system www.aspergillus.man.ac.uk
The spectrum of aspergillosis Frequency of aspergillosis Disfunction Immune system www.aspergillus.man.ac.uk
Acute IA The spectrum of aspergillosis Frequency of aspergillosis Disfunction Immune system www.aspergillus.man.ac.uk
Acute IA The spectrum of aspergillosis Subacute IA Frequency of aspergillosis Disfunction Immune system www.aspergillus.man.ac.uk
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
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
Review of the world literature • Medline, LILACS and EMBASE
Review of the world literature • Medline, LILACS and EMBASE • References were reviewed
Review of the world literature • Medline, LILACS and EMBASE • References were reviewed • Conference abstracts (www.aspergillus.man.ac.uk)
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.
Review of the world literature • Not included: • Primary cutaneous aspergillosis
Review of the world literature • Not included: • Primary cutaneous aspergillosis Neonate Andresen J, et al. Acta Paediatr 2005; 94: 761-2.
Review of the world literature • Not included: • Primary cutaneous aspergillosis Neonate Diabetes mellitus
Review of the world literature • Not included: • Primary cutaneous aspergillosis Neonate Diabetes mellitus Burn patient www.aspergillus.man.ac.uk
Review of the world literature • Not included: • Infections associated with intravascular devices
Review of the world literature • Not included: • Infections associated with intravascular devices Neutropenia
Review of the world literature • Not included: • Infections associated with intravascular devices Neutropenia HIV
Literature review • More than 500 cases were included
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
Endocarditis and aortitis • 124 cases
Endocarditis and aortitis • 124 cases 40 other cases
Endocarditis and aortitis • 124 cases • Male gender: 69.9%
Endocarditis and aortitis • 124 cases • Male gender: 69.9% • Median age: 43.5 years-old (0.8 to 71)
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%
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).
Key features • Absence of immunosuppression