Invasive Pulmonary Aspergillosis in Patients with Acute-On-Chronic Liver Failure

Journal of International Medical Research, Oct 2012

OBJECTIVE: Patients with acute-on-chronic liver failure (AoCLF) are prone to various infections, including invasive pulmonary aspergillosis (IPA). This retrospective study investigated the relationship between AoCLF and IPA in a large patient cohort.

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Invasive Pulmonary Aspergillosis in Patients with Acute-On-Chronic Liver Failure

Z WU 0 1 Z LING 0 1 F SHAO 0 1 J SHENG 0 1 L LI 0 1 0 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Department of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, Zhejiang, China 1 Professor Lanjuan Li State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Department of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, Zhejiang 310003, China - Downloaded from imr.sagepub.com by guest on October 16, 2014 Invasive Pulmonary Aspergillosis in Patients with Acute-on-chronic Liver Failure OBJECTIVE: Patients with acute-on-chronic liver failure (AoCLF) are prone to various infections, including invasive pulmonary aspergillosis (IPA). This retrospective study investigated the relationship between AoCLF and IPA in a large patient cohort. METHODS: Twenty-nine out of 470 patients with AoCLF, who were diagnosed with definite or probable IPA by clinical and laboratory parameters and were treated with voriconazole, were analysed for predisposing factors for IPA and clinical outcome. RESULTS: Imaging findings, such as the halo sign and increased white blood cell count, contributed to the early diagnosis of IPA. Patients with AoCLF and IPA experienced fever, cough and chest pain and, despite treatment with antifungal therapy, most (25/29 patients) died within 7 days. Possible risk factors for IPA included prolonged antibiotic therapy and dexamethasone exposure. CONCLUSIONS: AoCLF with prolonged antibiotic therapy and dexamethasone exposure carries a high risk for IPA. AoCLF patients with IPA involved in this study exhibited fever, cough, chest pain and increased white blood cell count, and their imaging findings were useful for the early diagnosis of IPA. Aspergillus spp. cause a wide spectrum of lung diseases, and are commonly isolated from soil, plant debris and indoor environments, including hospitals. Invasive pulmonary aspergillosis (IPA) is a potentially severe and frequently fatal early complication in certain immunocompromised and immunosuppressed aZ Wu and Z Ling contributed equally to this work. patients, such as transplant recipients and chemotherapy patients, with a mortality rate exceeding 90% in these patients.1 4 Chronic necrotizing pulmonary aspergillosis and Aspergillus spp. pneumonia, often with dissemination, are two well-known forms of this invasive disease.5,6 IPA mainly occurs in patients with malignancy who experience deep and prolonged neutropenia, but there are other established risk factors (such as high-dose, long-term corticosteroid therapy Downloaded from imr.sagep1ub9.co5m 8by guest on October 16, 2014 or advanced forms of acquired immunodeficiency syndrome).7 Patients with liver disease, especially liver failure, are often immunocompromised and are also prone to various infections including bacterial, viral and fungal infections such as IPA.8 12 Prodanovic et al.13 reported four cases of IPA in patients with Child-Pugh class C liver cirrhosis in a critical care setting, which is considered a possible risk factor for IPA. The diagnosis of IPA can be elusive because the fungus is difficult to isolate; in addition, its symptoms and signs are not specific, and the effects of antifungal agents and duration of treatment for IPA remain inadequate. Together, these are major complicating factors for immunocompromised patients and might be associated with increased mortality rates. Although IPA is the major factor associated with poor prognosis, there has been no largescale analysis of IPA in patients with liver disease, especially acute-on-chronic liver failure (AoCLF), which denotes an acute deterioration of known or unknown chronic liver disease or a gradual decompensation of end-stage liver disease. The current study determined the clinical presentation, predisposing factors and outcome of IPA in patients with AoCLF. Possible risk factors for IPA and treatment regimens were analysed in these patients, in an effort to determine the basis for the high mortality rate observed. Patients and methods STUDY POPULATION This retrospective study included patients with AoCLF who were admitted to the State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Department of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, China, between July 2007 and December 2010. Patients with acute deterioration in liver function over 2 4 weeks with a defined inflammation-related precipitant (infection or alcoholic hepatitis), leading to: severe progressive clinical deterioration despite > 48 h supportive care; increasing jaundice (serum bilirubin > 100 mol/l); evidence of abnormal coagulation (defined as an international normalized ratio [INR] 1.5); and either encephalopathy (grade 2) or hepatorenal syndrome (HRS) in those with clinical, radiological, biochemical and histological evidence of cirrh (...truncated)


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Z Wu, Z Ling, F Shao, J Sheng, L Li. Invasive Pulmonary Aspergillosis in Patients with Acute-On-Chronic Liver Failure, Journal of International Medical Research, 2012, pp. 1958-1965, 40/5, DOI: 10.1177/030006051204000537