Laura Meinke

Tuberculosis in Liver Transplant Recipients: A Systematic Review and Meta-Analysis of Individual Patient Data

Mycobacterium tuberculosis (MTB) causes substantial morbidity and mortality in liver transplant recipients. We examined the efficacy of isoniazid latent Mycobacterium tuberculosis infection (LTBI) treatment in liver transplant recipients and reviewed systematically all cases of active MTB infection in this population. We found 7 studies that evaluated LTBI treatment and 139 cases of active MTB infection in liver transplant recipients. Isoniazid LTBI treatment was associated with reduced MTB reactivation in transplant patients with latent MTB risk factors (0.0% versus 8.2%, P = 0.02), and isoniazid‐related hepatotoxicity occurred in 6% of treated patients, with no reported deaths. The prevalence of active MTB infection in transplant recipients was 1.3%. Nearly half of all recipients with active MTB infection had an identifiable pretransplant MTB risk factor. Among recipients who developed active MTB infection, extrapulmonary involvement was common (67%), including multiorgan disease (27%). The short‐term mortality rate was 31%. Surviving patients were more likely to have received 3 or more drugs for MTB induction therapy (P = 0.003) and to have been diagnosed within 1 month of symptom onset (P = 0.01) and were less likely to have multiorgan disease (P = 0.01) or to have experienced episodes of acute transplant rejection (P = 0.02). Compared with the general population, liver transplant recipients have an 18‐fold increase in the prevalence of active MTB infection and a 4‐fold increase in the case‐fatality rate. For high‐risk transplant candidates, isoniazid appears safe and is probably effective at reducing MTB reactivation. All liver transplant candidates should receive a tuberculin skin test, and isoniazid LTBI treatment should be given to patients with a positive skin test result or MTB pretransplant risk factors, barring a specific contraindication. Liver Transpl 15:894–906, 2009.

Role of Bronchoalveolar Lavage Diagnostics in Fungal Infections

Although a biopsy may need to be performed in complicated patients, bronchoalveolar lavage (BAL) is an important adjunct to the diagnosis of pulmonary and disseminated fungal infections. Culture is the gold standard for diagnosis in many instances, but cytologic and morphologic analysis is often diagnostic. Although newer molecular and antigen techniques may be applied to BAL samples, the role of such tests is yet to be defined for many pathogens.

Advances in the management of chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD), the fourth leading cause of death, seems to be increasing in worldwide prevalence, and carries with it a significant health and economic burden. Smoking cessation is the only available intervention proven to halt disease progression. The authors discuss the role of the newly approved agent, varenicline, in promotion of smoking cessation. The remainder of presently available therapies treat the symptoms of COPD, but do not impact progression of disease. As the understanding of the pathogenesis of COPD improves, new targets for therapies are emerging. Given the large number of potential targets and the results of recent studies, it seems unlikely that a single new agent will result in a cure. Rather, management of COPD should involve a multi-pronged approach including smoking cessation, bronchodilators, treatment of infection, and eventual targeting of inflammatory pathways and genetic predispositions. In this article, the authors discuss presently available therapies as well as agents under development.

Fluid management in hospitalized patients

Intravenous fluid administration is critical to the care of hospitalized patients. Despite the lack of a clear consensus on fluid administration, one may use the principles in this article to develop an organized framework for patient care.

Coccidioidomycosis among persons undergoing lung transplantation in the coccidioidal endemic region

Coccidioidomycosis, an endemic fungal infection, is more likely to be symptomatic and severe among those receiving allogeneic transplants. While several case series have been published for various transplanted organs, none has described the incidence and outcomes in those receiving lung transplants within the coccidioidal endemic region.

GIANT GASTRIC ULCERS IN CHRONIC SPINAL CORD INJURY PATIENTS

Gastric ulcers cause significant morbidity and mortality to patients with spinal cord injuries. Case reports of three patients with gastric ulcers and chronic spinal cord injuries. Review of the medical literature using MEDLINE ranging from 1975 to 2004. We describe three cases of severe, complicated gastric ulcers in this population. Two cases involve gastric ulcers that eroded into major mesenteric arteries, leading to one fatality. One of these cases revealed a gastric ulcer that looked like a mass because of intralumenal herniation of serosal fat. Diagnosis of ulcer disease is challenging in this patient population as they often do not endorse focal symptoms. Gastroenterologists and other practitioners evaluating chronic spinal cord injury patients should be aware of the potential for giant gastric ulcers, even with benign clinical presentations.