François Mosimann

Clinical significance of Candida isolated from peritoneum in surgical patients.

Over a 2-year period, all surgical patients from whom Candida was isolated from intra-abdominal specimens were evaluated. All but 1 of the 49 evaluable patients had either a spontaneous perforation (57%) or a surgical opening of the gastrointestinal tract (41%). Candida caused infection in 19 patients (39%), of whom 7 had an intra-abdominal abscess and 12 peritonitis. In the other 30 patients (61%), there were no signs of infection and specific surgical or medical treatment was not required. Candida was more likely to cause infection when isolated in patients having surgery for acute pancreatitis than in those with either gastrointestinal perforations or other surgical conditions. The development of a clinical infection was significantly associated with a high initial or increasing amount of Candida in the semiquantitative culture. Surgery alone failed in 16 of 19 patients (84%), of whom 7 died and 9 recovered after combined antifungal and surgical treatment. The overall mortality and the mortality related to infections were significantly higher in the patients with intraabdominal candidal infections than in those without such infections.

Determinants of protracted cytomegalovirus infection in solid-organ transplant patients.

Background. Recurrent infection frequently follows the response to the initial treatment of cytomegalovirus (CMV) infection in solid-organ transplant (SOT) recipients. The objective of this study was to describe the course of CMV infection in SOT patients and to identify factors that would predict protracted CMV infection with recurrences. Methods. Quantitative polymerase chain reaction (PCR) assay for CMV DNA in leukocytes and in plasma were used to assess viral load changes retrospectively in consecutive SOT patients, whose CMV infection episodes had been attended therapeutically or preemptively using quantitative blood culture. Results. Among 101 SOT patients, CMV infection occurred in 63, of whom 32 developed recurrent infection after the initial episode. In patients with recurrent infection, PCR indicated that a majority (27) of recipients had high level of CMV DNA in peripheral blood leukocytes and plasma throughout a protracted (≥1 month) period including after preemptive or therapeutic ganciclovir courses. Predictors of protracted high-level infection were increasing age, CMV donor seropositivity, and all measures of viral load during the initial episode. CMV recipient seropositivity protected strongly against protracted infection. End of treatment plasma CMV DNA best discriminated between patients who did or did not develop protracted infection. Conclusions. In SOT patients, protracted CMV infection is associated with increasing age, donor seropositivity, recipient seronegativity, and high viral load during the first episode. End of therapy plasma CMV DNA level best predicts the occurrence of protracted infection. In patients with a high risk of protracted infection, prophylaxis is likely to be particularly cost effective.

Angiotensin II mediates catecholamine and neuropeptide Y secretion in human adrenal chromaffin cells through the AT1 receptor

The aim of the present work was to study the effect of angiotensin II (Ang II) on catecholamines and neuropeptide Y (NPY) release in primary cultures of human adrenal chromaffin cells. Ang II stimulates norepinephrine (NE), epinephrine (EP) and NPY release from perifused chromaffin cells by 3-, 2- and 12-fold, respectively. The NPY release is more sustained than that of catecholamines. We found that the receptor-AT(2) agonist, T(2)-(Ang II 4-8)(2) has no effect on NE, EP and NPY release from chromaffin cells. We further showed that Ang II increases intracellular Ca(2+) concentration ([Ca(2+)](i)). The selective AT(1)-receptor antagonist Candesartan blocked [Ca(2+)](i) increase by Ang II, while T(2)-(Ang II 4-8)(2) was ineffective. These findings demonstrate that AT(1) stimulation induces catecholamine secretion from human adrenal chromaffin cells probably by raising cytosolic calcium.

Recurrent cytomegalovirus disease, visceral leishmaniosis, and Legionella pneumonia after liver transplantation: a case report

PurposeRecurrent cytomegalovirus (CMV) disease is a frequent complication of liver transplantation. Visceral leishmaniosis in a transplant recipient is, on the other hand, extremely rare and only two cases of kala-azar have been described after liver transplantation. Immunosuppressed patients are known to be at risk of Legionella infection and the relationship between infection with this organism and hospital water supplies has been well described. These three diseases carry a high mortality rate. Our report examines the potential relationship between these complications.Clinical featuresWe describe the case of a liver transplant recipient who presented the three complications successively and survived. After reviewing the literature, we explore hypotheses linking these infections and discuss treatment strategies.ConclusionsIn the patient described, infection with leishmania probably occurred months prior to the clinical presentation, a delay that matches the incubation period of kala-azar. The simultaneous onset of leishmaniosis and of a high CMV viremia may have been a coincidence. However, CMV infection has been shown to be an independent predictor of invasive fungal infection in liver transplant recipients. CMV does indeed have a suppressive effect on the humoral and cellular immune responsein vitro as well asin vivo. The clinical manifestations of leishmaniosis may, therefore, have been precipitated in this patient by the additive immunosuppressive effect of antirejection drugs and CMV.RésuméObjectifL’linfection récurrente au cytomégalovirus (CMV) est une complication fréquente de la transplantation hépatique. La leishmaniose viscérale chez un receveur d’organe est, par contre, extrêmement rare et on ne rapporte que deux cas de kalaazar à la suite d’une greffe de foie. Les patients immunodéprimés sont à risque d’infections à Légionella et la relation entre cet organisme et l’alimentation en eau des hôpitaux a été bien décrite. Ces trois maladies présentent un taux de mortalité élevée. Nous étudions ici la relation possible entre ces complications.Éléments cliniquesNous décrivons le cas d’un patient greffé du foie qui a présenté successivement les trois complications et a survécu. Après avoir passé en revue les publications, nous explorons des hypothèses pouvant relier ces infections et discutons des traitements possibles.ConclusionChez ce patient, l’infection à Leishmania est probablement survenue plusieurs mois avant les manifestations cliniques, ce qui correspond à la période d’incubation du kalaazar. La survenue simultanée d’une leishmaniose et d’une importante virémie au CMV pourrait n’être qu’une coïncidence. Cependant, l’infection au CMV s’est révélée un prédicteur indépendant d’infection fongique invasive chez les receveurs d’un foie. Le CMV a certainement un effet inhibiteur sur la réponse immunitaire humorale et cellulaire, in vitro aussi bien qu’in vivo. Les manifestations cliniques de la leishmaniose peuvent donc avoir été précipitées par l’effet immunodépresseur supplémentaire des médicaments antirejet et du CMV.

Schistosomal appendicitis in pregnancy

Acute appendicitis is the most common acute surgical infection during pregnancy. Although usually pyogenic in origin, parasitic infections account for a small percentage of cases. Despite the relatively high prevalence of acute appendicitis in our environment, it is not commonly associated with schistosomiasis. We report here the association of pregnancy and appendicitis caused by Schistosoma haematobium. Schistosomiasis is very common complication of pregnancy in hyperendemic areas. Schistosome egg masses can lodge throughout the body and cause acute inflammation of the appendix, liver and spleen. Congestion of pelvic vessels during pregnancy facilitates passage of eggs into the villi and intervillous spaces, causing an inflammatory reaction. Tourism and immigration make this disease a potential challenge for practitioners everywhere.

Effect of liver transplantation on hepatic glucose metabolism in a patient with type I glycogen storage disease.

BACKGROUND In type I glycogenosis, mutation of the glucose-6-phosphatase gene results in absent glucose-6-phosphatase activity in liver cells leading to fasting hypoglycemia. Liver transplantation is expected to normalize glucose homeostasis. METHODS Endogenous glucose production (6,6 2H2 glucose) was measured after an overnight fast and during exogenous 13C-labeled glycerol infusion in a patient with glycogenosis type I 24 months after liver transplantation and in a group of healthy subjects. RESULTS Compared with healthy subjects, the glycogenosis patient had normal fasting glucose production and glucose and insulin concentrations after liver transplantation, but mildly elevated plasma glucagon concentrations. Gluconeogenesis from exogenous glycerol (13C glucose synthesis) was similar and did not lead to enhancement of glucose production in both healthy controls and the patient. CONCLUSIONS Liver glucoregulatory function is restored by orthotopic liver transplantation in type I glycogenosis.

Laparoscopic procurement of kidney grafts from living donors does not impair initial renal function.

THE PERSISTENT SHORTAGE of kidneys available for transplantation has stimulated live donation. The excellent results obtained with both genetically related and unrelated donors have increased this trend. The recent description of laparoscopic allograft harvesting has promoted this option even further. The benefits of the laparoscopic procedure for the donor have been extensively described, but whether the functional results of the laparoscopically procured grafts are equivalent to those obtained by the classical open method remains to be proved. In this single-center study we compared the early function of the grafts harvested by laparoscopy and by the open technique.

Progress in Diagnostic Immunoscintigraphy and First Approach to Radioimmunotherapy of Colon Carcinoma

More than thirty years ago, Pressman and Korngold (1953) and Bale and Spar (1957) reported the first experiments indicating that radiolabeled antibodies injected into a tumor bearing animal can localize preferentially into the tumor, which could be detected by external scanning. These early studies, however, were performed with poorly characterized antibodies obtained by absorption and elution from tumor cells or crude tumor fractions. Thus, this type of antibodies could not be used for clinical applications.

Retransplantation of the liver after side‐to‐side caval anastomosis

Abstract Caval reconstruction in orthotopic liver transplantation is generally performed by two end‐to‐end anastomoses, using a portal and caval‐axillary bypass to sustain hemodynamic stability. In the “piggyback” modification, the donors suprahepatic inferior vena cava (IVC) is anastomosed end‐to‐side to the recipients preserved IVC. We have used a recently described variant of the piggyback in 18 patients in whom both IVCs are anastomosed side‐to‐side. We report two patients who needed three retransplants after this reconstruction and conclude that regrafting can be performed in a quick and safe manner.

The Use of Executed Prisoners As a Source of Organ Transplants in China Must Stop

The statement by G.M. Danovitch, M.E. Shapiro and J. Lavee that ‘The use of executed prisoners as a source of organ transplants in China must stop’ (1) cannot be disputed. However, the strategies they suggest to achieve this goal sound like a policeman approach that is unlikely to appeal to Chinese colleagues and politicians amenable to change. Another disturbing point is that the authors forget that Western democracies too, including the United States, used prisoners as ‘donors’ only a few decades ago, thus limiting their moral authority (2–4).