Başkent Üniversitesi Dergileri

Permanent URI for this collectionhttps://hdl.handle.net/11727/13093

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Acute Appendicitis After Diaphragmatic Hernia After Pediatric Liver Transplant
(Başkent Üniversitesi, 2011-02) Aktas, Sema; Haberal, Mehmet; Bilezikci, Banu; Coskun, Mehmet; Ozcay, Figen; Karakayali, Hamdi; Sevmis, Sinasi
Multiple complications in liver transplant have been described in the literature. However, appendicitis and diaphragmatic hernia have rarely been reported after solid-organ transplant. The clinical presentation of appendicitis is similar to that of nontransplant patients, but complications are more frequent, because the majority of the patients did not have leukocytosis. Diaphragmatic hernia can present with a variety of atypical clinical symptoms. In this report, 1 patient who developed a diaphragmatic hernia and appendicitis after liver transplant is presented. A 2-year-old boy with end-stage liver cirrhosis owing to progressive familial intrahepatic cholestasis type-2 received a living-donor liver transplant. The posttransplant course was complicated. The diagnosis of diaphragmatic hernia was confirmed by thoracoabdominal computed tomography, and we decided to proceed with surgical repair. The patient had evidence of perforation, and the appendix was removed. After repositioning the intestine in the abdomen, a chest tube was placed, and the defect repaired with interrupted polypropylene sutures. The patient recovered after surgery without untoward sequelae.
Acute Gastric Variceal Bleeding During Orthotopic Liver Transplant
(Başkent Üniversitesi, 2010-09) Shapiro, David P.; Aniskevich, Stephen; Shine, Timothy S.
We present a case of intraoperative gastric variceal bleeding during liver transplant. After an uneventful induction and surgical dissection, our patient developed hemodynamic instability during the anhepatic phase. We believe that an increase in portal pressures, owing to clamping of the portal system, led to spontaneous variceal rupture; however, placement of an oral gastric tube or transesophageal echocardiography probe may have contributed to this also. After intraoperative banding, the patient was stabilized and surgery proceeded uneventfully. The patient had no long-term sequelae. Anesthesiologists involved in the care of patients with end-stage liver disease should be aware of this infrequent intraoperative complication and be prepared to treat it appropriately.
Aspergillus Fumigatus Spondylodiskitis in Renal Transplant Patient: Voriconazole Experience
(Başkent Üniversitesi, 2011-08) Ersoy, Alparslan; Ener, Beyza; Akalin, Halis; Oruc Koc, Aysegul; Dizdar, Oguzhan Sitki
The incidence of invasive aspergillosis has increased after solid organ transplant. However, aspergillus osteomyelitis in vertebrae is rare. We report a case of aspergillus spondylodiskitis after pulmonary aspergillosis in a renal transplant recipient. He was treated by antifungal therapy and surgical intervention. The transplantist should be alert for a diagnosis of aspergillus spondylodiskitis in recipients who developed back pain after aspergillosis infection in other sites.
Bilateral Transversus Abdominis Plane Block for Managing Pain After a Pancreas Transplant
(Başkent Üniversitesi, 2011-08) Aniskevich, Stephen; Torp, Klaus D.; Clendenen, Steven R.
The authors report the first clinical application of a bilateral transversus abdominis plane block for treating pain after a pancreas transplant. In this case, a 36-year-old chronic opioid user presented postoperatively with severe incisional pain following a pancreas transplant. The pain was not ameliorated with opioids and was successfully treated with the administration of bilateral transversus abdominis plane blocks with 0.5% ropivicaine. Pain relief lasted for 6 hours.
Chronic Myeloid Leukemia Within a Year of Kidney Transplant With Elevated Alkaline Phosphatase Correlated With Imatinib Therapy
(Başkent Üniversitesi, 2011-10) Sayar, Hamid; Mehta, Rakesh; Taber, Tim E.; Sharfuddin, Asif A.
The incidence of certain malignancies is significantly higher after organ transplant. However, there are rare reports of chronic myeloid leukemia in the posttransplant setting. The average reported interval between a transplant and the diagnosis of chronic myeloid leukemia is 44 months (range, 10-96 mo). We report 2 patients with chronic myeloid leukemia within 1 year of a kidney transplant, which is significantly shorter than those previously reported. Both patients were receiving mycophenolate mofetil and tacrolimus for immunosuppression. They were treated with imatinib for chronic myeloid leukemia, and both patients demonstrated an isolated elevation of serum alkaline phosphatase that was directly correlated with imatinib. Despite a potential interaction between the 2 drugs, blood levels of tacrolimus and imatinib were not elevated during the course of treatment. Isolated elevation of alkaline phosphatase in this particular setting has not been reported previously.
Combination Antifungal Therapy for Invasive Pulmonary Aspergillosis in a Heart Transplant Recipient
(Başkent Üniversitesi, 2011-08) Beiras-Fernandez, Andres; Kaczmarek, Ingo; Reichart, Bruno; Ueberfuhr, Peter; Michel, Sebastian; Nickel, Thomas; Bigdeli, Amir K.
Invasive pulmonary aspergillosis is a severe complication after solid organ transplant, with a high mortality rate. We present a 45-year-old male heart transplant recipient who developed fever, progressive worsening of dyspnea, and productive cough without response to antibiotics. Diagnosis of invasive pulmonary aspergillosis was made based on clinical, laboratory, and radiographic findings. The patient was treated successfully with combined antifungal therapy (voriconazole and micafungin). This case report highlights the importance of a high degree of clinical suspicion to allow curative treatment of invasive aspergillosis and the efficiency of new antifungal drugs.
Extracorporeal Membrane Oxygenation Bridging to Lung Transplant Complicated by Heparin-Induced Thrombocytopenia
(Başkent Üniversitesi, 2010-12) Dolch, Michael E.; Munich Lung Transplant Group; Irlbeck, Michael; Behr, Jürgen; Beiras-Fernandez, Andres; Überfuhr, Peter A.; Hatz, Rudolf; Frey, Lorenz
In patients with acute respiratory failure and life-threatening impairment of pulmonary gas exchange, venovenous extracorporeal membrane oxygenation offers further therapeutic options. During extracorporeal membrane oxygenation treatment, systemic anticoagulation is usually achieved by heparin administration, which exposes patients to the risk of heparin-induced thrombocytopenia type II. We present a patient with acute respiratory distress syndrome on venovenous extracorporeal membrane oxygenation who experienced heparin-induced thrombocytopenia type II and in whom anticoagulation was continued with argatroban. Because respiratory failure did not resolve, the patient was bridged to lung transplant with extracorporeal membrane oxygenation. Argatroban anticoagulation was safely used until lung transplant (on day 114 after extracorporeal membrane oxygenation initiation) and after transplant in the presence of hepatic failure.
Flupirtine-induced Hepatic Failure Requiring Orthotopic Liver Transplant
(Başkent Üniversitesi, 2011-08) Klein, Fritz; Neuhaus, Peter; Seehofer, Daniel; Rudolph, Birgit; Glanemann, Matthias
We present the case of a 48-year-old otherwise healthy man who required an urgent liver transplant owing to acute liver failure after flupirtine treatment. After 3 months of daily flupirtine intake as treatment for pseudoradicular pain syndrome, he presented at our institution with signs of jaundice and hepatic encephalopathy. Laboratory results showed elevated liver transaminases, and the liver histopathology supported the assumed drug-induced liver injury. After listing him for an urgent liver transplant, he was given a liver graft from a 21-year-old man. Despite a rejection episode on day 11 after the surgery (which was successfully treated by steroid pulse therapy), the postoperative course was uneventful and the patient recovered completely. To the best of our knowledge, this is the first report of a liver transplant for acute liver failure after taking flupirtine.
Hemophagocytic Lymphohistiocytosis After Lung Transplant: Report of 2 Cases and a Literature Review
(Başkent Üniversitesi, 2011-06) Diaz-Guzman, Enrique; Hayes, Don; Kesler, Melissa V.; Hobbs, Stephen B.; Dong, Bei
Hemophagocytic lymphohistiocytosis is a rare and often fatal disease that may occur in solid organ transplant recipients. Here, we describe 2 patients who developed hemophagocytic lymphohistiocytosis after having a lung transplant and present a review of all cases of hemophagocytic lymphohistiocytosis occurring in solid organ transplant recipients. Diagnosis of hemophagocytic lymphohistiocytosis relies on the association of clinical findings and the presence of hemophagocytosis. Clinical presentation is nonspecific and patients may present with unexplained sepsis or multiple organ failure. Management consists of treating the underlying process; but unfortunately, the prognosis is poor.
Hepatitis A Virus-related Late-onset Hepatic Failure: A Case Report
(Başkent Üniversitesi, 2011-04) Hayashi, Michihiro; Tanigawa, Nobuhiko; Haga, Hironori; Takeshita, Atsushi; Asakuma, Mitsuhiro; Hirokawa, Fumitoshi; Tsunematsu, Ichiro; Shimizu, Tetsunosuke
Late-onset hepatic failure, the least of the fulminant hepatic failures, has not occurred in patients with hepatitis A virus-related acute liver failure. We report a rare case of hepatitis A virus-related late-onset hepatic failure treated successfully by an emergent liver transplant. A 58-year-old Japanese woman who presented with fever and general malaise was diagnosed as having jaundice and liver dysfunction by a positive serum test for anti-hepatitis A virus IgM, which ultimately led to a diagnosis of acute hepatitis A virus-associated hepatitis. Despite intensive treatment, her general condition was poor, and she developed a hepatic coma 79 days from the onset of the disease. Under a diagnosis of hepatitis A virus-related late-onset hepatic failure, she was given a living-donor liver transplant 82 days from the start of the disease. The resected native liver revealed submassive necrosis with marked cholestasis, compatible with late-onset hepatic failure. Today, 5 years after the transplant, she is alive and well with no signs of recurrent hepatitis A virus-hepatitis. This case should alert the physician to the clinical management of a patient with hepatitis A virus-related acute liver failure.
Inhaled Pentamidine For Pneumocystis jiroveci Prophylaxis in a Heart Transplant Recipient With Allergy for Trimethoprim Sulfamethoxazole
(Başkent Üniversitesi, 2011-02) Altıntaş, Garip; Küçüker, Seref Alp; Hanedan, Onur; Diken, Özlem Erçen; Diken, Adem İlkay
Pneumocystis jiroveci is an important cause of mortality and morbidity among heart transplant recipients. This raises the question of prophylactic treatment for this infection. Trimethoprim-sulfamethoxazole is commonly used in P. jiroveci pneumonia prophylaxis with mild to severe adverse effects. We present the use of inhaled pentamidine as P. jiroveci prophylaxis in a patient with an allergy to trimethoprim sulfamethoxazole.
Lepromatous Leprosy in a Kidney Transplant Recipient: A Case Report
(Başkent Üniversitesi, 2011-06) Ardalan, Mohammadreza; Shoja, Mohammadali M.; Ghabili, Kamyar; Ghaffari, Alireza
Leprosy is a chronic granulomatous disease of the skin and peripheral nerves caused by Mycobacterium leprae. Among mycobacterial infections, leprosy is rare in renal transplant recipients. Here, we report the manifestations of lepromatous leprosy in a 41-year-old renal transplant recipient. Before the renal transplant, the patient had recurrent bullous lesions on his extremities with no systemic complaints. He was on an immunosuppressive regimen that included prednisolone (1 mg/kg/d), cyclosporine (6 mg/kg), and mycophenolate mofetil (2000 mg/d), and had 2 serologically confirmed acute episodes of cytomegalovirus infection that responded favorably to intravenous ganciclovir. The density of his bullous skin lesions decreased after renal transplant. During his regular posttransplant visits, we noticed a decrease in his eyebrow hairs on their lateral margins bilaterally. Later, he developed generalized, symmetric, erythematous papules. With a positive acid-fast bacilli with Fite staining, the results of a skin biopsy showed diffuse foamy histiocyte infiltration in the dermis. These findings are compatible with lepromatous leprosy. After antileprosy therapy, no deterioration of renal allograft function or lepra reactions was noted in a 4-month follow-up. Clinicians should consider leprosy in the differential diagnosis of skin lesions in immunocompromised hosts, and in particular, solid organ transplant recipients in endemic areas.
Leukoencephalopathy Syndrome After Living-donor Liver Transplantation
(Başkent Üniversitesi, 2011-04) Umeda, Yuzo; Fujiwara, Toshiyoshi; Yagi, Takahito; Utsumi, Masashi; Sato, Daisuke; Yoshida, Ryuichi; Shinoura, Susumu; Sadamori, Hiroshi; Matsuda, Hiroaki
Objectives: Leukoencephalopathy syndrome is a neurologic complication after organ transplantation caused predominantly by the neurotoxic effects of immunosuppressive agents on cerebral white matter. We determined the incidence and features of leukoencephalopathy syndrome in recipients after living-donor liver transplantations. Materials and Methods: We retrospectively investigated 205 patients who had a living-donor liver transplantation performed at our institution between August 1998 and October 2008. Results: Leukoencephalopathy syndrome developed in 7 of 205 patients (3.9%) and in 4.7% of the 150 patients treated with tacrolimus-based immunosuppression after their living-donor liver transplantation. The underlying diseases were alcoholic cirrhosis in 3 cases, viral cirrhosis in 2, biliary atresia in 1, and Wilson disease in 1. Time to clinical onset after tacrolimus medication was 15.6 days (range, 6-30 days). The neurologic symptoms included headache, confusion, myoclonus, seizures, and visual disturbances. The mean serum trough level of tacrolimus at clinical onset was not very high (11.7 ng/mL [range, 6.0-14.2 ng/mL]). T2-weighted magnetic resonance imaging in all cases showed diffuse high signal in the white matter of the frontal, parieto-occipital, and temporal lobes. Treatment with antihypertensives, anticonvulsants, and withdrawal of tacrolimus resulted in amelioration of symptoms and magnetic resonance imaging abnormalities. Six patients showed complete recovery, while the seventh had residual rigidity and cognitive impairment caused by hypoxia during a convulsion. Conclusions: Tacrolimus neurotoxicity can occur despite low trough levels; it depends on variations in pharmacokinetics, such as absorption and maximum concentration level. Early diagnosis and treatment of leukoencephalopathy syndrome should contribute to complete remission.
Liver Transplant for Mixed Capillary-cavernous Hemangioma Masquerading as Hepatocellular Carcinoma in a Patient With Hepatocellular Carcinoma
(Başkent Üniversitesi, 2011-10) Unal, Ethem; Teperman, Lewis; Morgan, Glyn; Xu, Ruliang; Aquino, Alger; Francis, Franto
Hemangioma is the most common benign tumor of the liver. Unlike cavernous hemangioma, hepatic capillary or mixed capillary-cavernous hemangioma is a rare type of tumor in adults. Clinical presentation of hemangioma may mimic that of hepatocellular carcinoma. Furthermore, radiologic features on computed tomography and magnetic resonance imaging may not be typical for hemangioma and can be confused with hepatocellular carcinoma. Symptomatic hemangiomas require some form of treatment, such as corticosteroids, interferon, radiation, arterial embolization, surgical resection, or liver transplant. In the present case study, we present a patient treated with liver transplant for hemangioma mimicking hepatocellular carcinoma. This case report illustrates the atypical imaging appearance of hemangioma and possible confusion it can cause in diagnosing hepatocellular carcinoma, especially in a hepatitis C carrier.
Liver Transplant in a Patient with Active Pulmonary Tuberculosis
(Başkent Üniversitesi, 2010-09) Yankol, Yucel; Kalayoglu, Munci; Acarli, Koray; Alan, Servet; Kanmaz, Turan; Kocak, Burak; Topaloglu, Serdar
Objectives: Immunosuppressive treatment generally increases the severity of active infection. Therefore, liver transplant is contraindicated in the presence of active tuberculosis. Despite the importance of supportive treatment, liver transplant is the only treatment for fulminant hepatic failure. Materials and Methods: We report a case of successful liver transplant for fulminant hepatic failure in the presence of active tuberculosis infection. Results: We immediately performed a liver transplant from a live donor. The patient received low-dose immunosuppressive treatment and antituberculosis treatment. The patient was cured and discharged on the 25th day after surgery. We stopped antituberculosis treatment 10 months after discharge. The patient has been followed for 32 months after transplant with normal graft function and has been free of pulmonary tuberculosis infection. Conclusions: Liver transplant can be performed in cirrhotic patients with active infections, such as tuberculosis, as a life-saving procedure.
Liver Transplantation From an Upper Midline Incision
(Başkent Üniversitesi, 2011-08) Kayaalp, Cuneyt; Yilmaz, Sezai; Aydinli, Bulent; Ozgor, Dincer; Baskiran, Adil; Unal, Bulent; Aydin, Cemalettin
Objectives: To evaluate the minimally invasive incision to the recipient of a liver transplant. Materials and Methods: A 55-year-old man with cirrhosis due to hepatitis B accompanied by hepatocellular carcinoma underwent a right lobe, living-donor liver transplant using an 18-cm long, upper midline incision. The recipient hepatectomy was performed from the left to the right side (from medial to lateral). Deep retractors and long surgical instruments were preferred. Results: The surgical procedure was completed without problem. Both the recipient hepatectomy and implantation of the right liver took 8 hours. Postoperative recovery of the patient was rapid, and he was discharged 8 days after surgery, uneventfully. Conclusions: An upper midline incision can be preferred for liver transplant for selected cases. Minimally invasive surgery is an option for liver transplant recipients as well.
Meningoencephalitis With Aspergillus and Mycobacterium Tuberculosis in a Renal Transplant Recipient
(Başkent Üniversitesi, 2011-02) Petramfar, Peyman; Rahmati, Hashem; Davarpanah, Mohammad Ali; Ashraf, Mohammad Hosein; Yousefian, Marzieh
Objectives: We report a case of central nervous system coinfection with 2 types of opportunistic organisms—Aspergillus and Mycobacterium tuberculosis—in a 33-year-old woman who underwent a renal transplant. Materials and Methods: She developed a high-grade fever and right-sided weakness 1 month after the transplant while on mycophenolate mofetil, prednisolone, and cyclosporine. Results: Brain magnetic resonance imaging revealed multiple mass lesions with peripheral ring enhancement. Colony-stimulating factor polymerase chain reaction was positive for Aspergillus and Mycobacterium tuberculosis. Conclusions: Broad-spectrum antibiotics, antituberculous agents, and amphotericin were started. Unfortunately, the woman’s condition deteriorated, and she died 2 weeks after admission to the hospital.
Mucocele of the Cystic Duct Remnant After Orthotopic Liver Transplant: A Problem Revisited
(Başkent Üniversitesi, 2011-06) Chatterjee, Suvadip; French, Jeremy J.; Sen, Gourab; Oppong, Kofi Ernest; Scott, John; Bassendine, Margaret Fiona; Hudson, Mark; Das, Debasish
Mucocele of the cystic duct remnant is an uncommon hepatobiliary complication of a liver transplant. Current practice usually involves either excising the cystic duct, or incorporating the distal end of the transected cystic duct into the suture line of the biliary anastomosis to ensure drainage. We report a patient who developed cystic duct remnant mucocele after the latter approach was adopted. We believe that this is likely related to delayed anastomotic stricturing, which prevented draining from the remnant cystic duct. We also discuss the incidence, pathology, investigations, and treatment of this condition.
Portal Biliopathy Treated With Living-donor Liver Transplant: Index Case
(Başkent Üniversitesi, 2011-04) Gupta, Subash; Wadhawan, Manav; Vij, Vivek; Goyal, Neerav; Singhal, Ashish
Portal biliopathy refers to abnormalities of the entire biliary tract in patients with extrahepatic portal vein obstruction. Most of the patients are asymptomatic. However, more than 80% of patients show characteristic morphologic features on endoscopic retrograde cholangiopancreatography. Symptomatic cases usually require therapy. The proposed therapies include endoscopic dilatation and stenting of the common bile duct, portosystemic shunt with splenectomy, meso Rex bypass, and occasionally, bilioenteric bypass. In patients with failed stenting and nonshuntable anatomy, liver transplant may be the only option, provided an adequate inflow can be achieved to the graft. To the best of our knowledge, only 2 cases have been reported, and these have undergone deceased-donor liver transplant for portal biliopathy. We report an index case treated successfully with living-donor liver transplant.
Postrenal Transplant Urinary Leakage Caused by Segmental Infarction of a Renal Allograft Treated by Partial Nephrectomy
(Başkent Üniversitesi, 2011-04) Salehipour, Mehdi; Malek-hosseini, Seyed Ali; Bahador, Ali; Salahi, Heshmatollah; Nikeghbalian, Saman; Eshraghian, Ahad; Roozbeh, Jamshid
Kidney transplant is the final treatment for patients with end-stage renal disease. Urinary leakage is the most-common surgical complication early after transplant. Another complication in the early posttransplant period is segmental allograft infarction. We report a kidney recipient who developed urinary leakage secondary to a segmental infarction of the upper pole of the transplanted kidney 2 months after transplant. The patient was treated successfully by a partial nephrectomy of the infracted upper lobe of the kidney. Three months after the partial nephrectomy of the allograft, serum blood urea nitrogen and creatinine were normal, and the patient was able to partake in her daily activities. Partial nephrectomy in the context of infarction of a kidney allograft is safe and can be used in similar cases.