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      Multiple Brain Abscesses Due to Aspergillus Fumigatus in a Patient With Liver Cirrhosis : A Case Report

      case-report
      , MD, , MD, , PhD, , MD, , MD, , MD, PhD, , MD, , MD
      Medicine
      Wolters Kluwer Health

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          Abstract

          Invasive cerebral aspergillosis always developed in immunocompromised host. Early diagnosis may save life in this critical condition; however, it is difficult to reach. Herein, we presented an unusual case of invasive cerebral aspergillosis in a cirrhotic patient.

          A 47-year-old man presented with progressive deterioration of consciousness for three days. The patient had a history of alcoholic liver cirrhosis, Child-Pugh class C. Magnetic resonance imaging (MRI) of brain showed multi-focal parenchymal lesions, which was consistent with multiple brain abscesses. The diagnosis of invasive cerebral aspergillosis was made by molecular based laboratory methods including Aspergillus galactomannan antigen assay and oligonucleotide array. Despite treatment with the antifungal agent, Amphotericin B, the patient died at the ninth day of hospitalization.

          Our findings suggest that liver cirrhosis can be one of risk factors of invasive cerebral aspergillosis, and support the diagnosing usefulness of MRI, Aspergillus galactomannan antigen assay, and oligonucleotide array.

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          Identification of medically important molds by an oligonucleotide array.

          Infections caused by fungi have increased in recent years. Accurate and rapid identification of fungal pathogens is important for appropriate treatment with antifungal agents. On the basis of the internal transcribed spacer 1 (ITS 1) and ITS 2 sequences of the rRNA genes, an oligonucleotide array was developed to identify 64 species (32 genera) of clinically important filamentous (or dimorphic) fungi. These 64 species included fungi causing superficial, cutaneous, subcutaneous, and invasive infections. The method consisted of PCR amplification of the ITS regions using a pair of universal primers, followed by hybridization of the digoxigenin-labeled PCR products to a panel of species- or group-specific oligonucleotides immobilized on a nylon membrane. Of 397 fungal strains (290 target and 107 nontarget strains) tested, the sensitivity and specificity of the array was 98.3% (285/290) and 98.1% (105/107), respectively. Misidentified strains were usually those belonging to the same genus of the target species or having partial homology with oligonucleotide probes on the membrane. The whole procedure can be finished within 24 h starting from isolated colonies; reproductive structures, which are essential for the conventional identification methods, are not needed. In conclusion, the present array is a powerful tool for identification of clinically important filamentous fungi and may have the potential to be continually extended by adding further oligonucleotides to the array without significantly increasing the cost or complexity.
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            Invasive aspergillosis in patients with cirrhosis, a case report and review of the last 10 years.

            Untreated invasive aspergillosis (IA) is lethal, yet diagnosis is often delayed. Recognising the risk factors can lead to earlier diagnosis. We present a case of an invasive pulmonary aspergillosis in a patient with cirrhosis, who had been treated with corticosteroids for 2.5 weeks for alcoholic hepatitis. He was successfully treated with liposomal amphotericin B and caspofungin (first in combination, then caspofungin monotherapy).
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              Cerebral aspergillus infection in pediatric acute lymphoblastic leukemia induction therapy

              Angioinvasive pulmonary infection from filamentous fungi is not an uncommon occurrence in immunocompromised patients like acute lymphoblastic leukemia (ALL). Rarely, these lesions can spread via the hematogenous route and involve multiple visceral organs. We report a case of a 14-year-old boy with ALL who developed angioinvasive pulmonary aspergillosis early in the course of induction therapy, which was followed by hematogenous dissemination and formation of multiple brain abscesses. The patient was treated with intravenous amphotericin B. There was no response to the therapy and the patient succumbed to disseminated infection. Postmortem lung biopsy confirmed angioinvasive pulmonary aspergillosis. Poor penetration of amphotericin B across the blood-brain barrier could be one of the contributory factors for poor response to antifungal therapy. We discuss the various antifungal agents with respect to their penetration in brain.
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                Author and article information

                Journal
                Medicine (Baltimore)
                Medicine (Baltimore)
                MEDI
                Medicine
                Wolters Kluwer Health
                0025-7974
                1536-5964
                March 2016
                07 March 2016
                : 95
                : 9
                : e2813
                Affiliations
                From the Department of Medicine (H-JT), Chi Mei Medical Center, Tainan, and Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan; Department of Intensive Care Medicine (WWL, CCL), Chi Mei Medical Center, Liouying, Tainan; Department of Medical Laboratory Science and Biotechnology (TCC), College of Medicine, National Cheng Kung University, Tainan; Department of Internal Medicine (M-CL, W-CK, C-JW), National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan; National Institute of Infectious Diseases and Vaccinology (C-JW), National Health Research Institutes, Tainan; Department of Medical Research (Y-CC), Chi Mei Medical Center, Tainan; and Department of Internal Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan.
                Author notes
                Correspondence: Chih-Cheng Lai, Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan (e-mail: dtmed141@ 123456gmail.com).
                Article
                02813
                10.1097/MD.0000000000002813
                4782847
                26945363
                710a7ad9-58e3-47b1-b5dc-6684b3b16733
                Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

                This is an open access article distributed under the Creative Commons Attribution-NoDerivatives License 4.0, which allows for redistribution, commercial and non-commercial, as long as it is passed along unchanged and in whole, with credit to the author. http://creativecommons.org/licenses/by-nd/4.0

                History
                : 18 December 2015
                : 14 January 2016
                : 17 January 2016
                Categories
                4900
                Research Article
                Clinical Case Report
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