Pulmonary tuberculosis in lung and heart-lung transplantation: fifteen years of experience in a single center in Spain

The increase in the number of solid organ transplants has resulted in an increased incidence of opportunistic infections, including infection by typical and atypical mycobacteria, with risk of developing tuberculosis. Pretransplant chemoprophylaxis with isoniazid has become increasingly common in an attempt to prevent the disease. The source of infection in tuberculosis (TB) may be difficult to identify. Infection may be caused by reactivation of a primary infection in the recipient, reactivation of a lesion from the donor lung, or primary infection. There are few reports on TB in lung transplantation. Incidence in the reported series ranges from 6.5% to 10%. Our series of 7 patients out of a total 271 patients (2.58%) represents a rate higher than reported for the general Spanish population, 26.7/10(5) inhabitants and for lung transplant candidates (0.18%). Our aim was to evaluate the incidence, clinical signs, and outcome of TB in our series of patients undergoing lung transplantation in the 15 years since inception of the program (February 1990 to December 2004). Morbidity and mortality was high (42.8%), but limited to patients in whom treatment was not administered or could not be successfully completed. However, early detection and treatment are essential.

Effects of perinatal asphyxia on cell proliferation and neuronal phenotype evaluated with organotypic hippocampal cultures

The present report summarizes studies combining an in vivo and in vitro approach, where asphyxia is induced in vivo at delivery time of Wistar rats, and the long term effects on hippocampus neurocircuitry are investigated in vitro with organotypic cultures plated at postnatal day seven. The cultures preserved hippocampus layering and regional subdivisions shown in vivo, and only few dying cells were observed when assayed with a viability test at day in vitro 27. When properly fixed, cultures from asphyxia-exposed animals showed a decreased amount of microtubule-associated protein-2 immunocytochemically positive cells (approximately 30%), as compared with that from controls. The decrease in microtubule-associated protein-2 immunocytochemistry was particularly prominent in Ammon's horn 1 and dentate gyrus regions (approximately 40%). 5-Bromo-2'deoxyuridine labeling revealed a two-fold increase in cellular proliferation in cultures from asphyxia-exposed, compared with that from control animals. Furthermore, confocal microscopy and quantification using the optical disector technique demonstrated that in cultures from asphyxia-exposed animals approximately 30% of 5-bromo-2'deoxyuridine-positive cells were also positive to microtubule-associated protein-2, a marker for neuronal phenotype. That proportion was approximately 20% in cultures from control animals. Glial fibrillary acidic protein-immunocytochemistry and Fast Red nuclear staining revealed that the core of the hippocampus culture was surrounded by a well-developed network of glial fibrillary acidic protein-positive cells and glial fibrillary acidic protein-processes providing an apparent protective shield around the hippocampus. That shield was less developed in cultures from asphyxia-exposed animals. The increased mitotic activity observed in this study suggests a compensatory mechanism for the long-term impairment induced by perinatal asphyxia, although it is not clear yet if that mechanism leads to neurogenesis, astrogliogenesis, or to further apoptosis.

Lymphoproliferative Disease After Lung and Heart-Lung Transplantation: First Description in Spain

Lymphoproliferative syndromes are the most common tumors in transplant recipients. More than 90% of posttransplantation lymphoproliferative syndromes (PTLS) are considered to be associated with Epstein-Barr virus, and 86% are of the B-cell line. Histopathology ranges from polymorphic-reactive to monomorphic forms. Clonality should be studied using molecular biology techniques. Clinically, a differentiation is usually made between early PTLS (occurring within 1 year after transplantation) and late PTLS, which occur as localized or disseminated nodal lymphomas. In localized forms, immunosuppression should be discontinued or decreased, and the involved area should be subsequently resected or irradiated. In disseminated cases, immunosuppression should be decreased and administration of acyclovir/ganciclovir should be considered. If this is not effective, treatment should be started with anti-CD20 monoclonal antibodies (rituximab). If no response occurs, use of chemotherapy, possibly with interferon, should be considered. Our aim was to report the incidence, clinical signs, and treatment in a series of patients undergoing lung transplantation (LTx).

MHC-F DNA sequences in bonobo, gorilla and orangutan

The major histocompatibility complex (MHC)-F class Ib locus shows a limited polymorphism, and the function of its mainly intracellular protein is not clear. We have identified human leucocyte antigen (HLA)-F orthologous DNA sequences in Pongidae in order to study the MHC-F gene evolution and its products' function. HLA-F orthologous cDNA transcripts are found in chimpanzee and in the new primate species studied (bonobo, gorilla and orangutan). Analyses of the predicted amino acid sequences and their comparison with other primate MHC-F proteins show that MHC-F may be a protein with a typical class I structure and that the key residues of the peptide-binding region (PBR) are highly conserved in MHC-F in all studied primates species. Thus, MHC-F conservation along the primate evolution suggests an important role in cellular physiology. It is possible that the MHC-F protein could be involved, together with MHC-G and MHC-E, in the natural killer (NK) cell activity regulation, although rhesus macaque does not express MHC-G and MHC-E orthologues. The evolutionary pathway of the six-base-pair deletion at exon 2 existing in some primates is put forward.

Aspergillus infections in lung transplant recipients: risk factors and outcome

This retrospective study of 251 lung transplant patients aimed to determine the prevalence, clinical presentation and mortality of Aspergillus infection in order to define specific risk factors and to compare survival in patients with and without infection. Aspergillus was isolated from 86 (33%) cases, which involved colonisation (n = 50), tracheobronchial lesions (n = 17) or invasive aspergillosis (n = 19). Overall, aspergillosis had an impact on survival (p < 0.05); in fact the 5-year mortality rate was substantially higher in single lung transplant recipients with bronchial anastomotic infection, and in those with late-onset infections and chronic rejection. A significant association (p < 0.05) was found between acute rejection and the time at which fungal infection was diagnosed. Aspergillus infection was not related to cytomegalovirus infection or treatment with corticosteroids. The mortality rate for invasive infections was 78% and was related to survival (p < 0.0001); invasive aspergillosis was also associated with chronic rejection (p < 0.05), but not with high corticosteroid doses (p 0.49) or use of tacrolimus (p 0.73). In conclusion, Aspergillus infection was associated with a reduction in the 5-year survival rate of lung transplant recipients, and this was particularly true for patients infected with the invasive forms and for patients with single lung transplants, bronchial anastomotic infection and chronic rejection. Isolation of Aspergillus spp. from respiratory samples preceded acute rejection, and may be a marker of graft dysfunction and/or airway inflammation. Close monitoring, or even pre-emptive antifungal therapy, is recommended for patients with chronic rejection or bronchial airway mechanical abnormalities and persistent Aspergillus colonisation.

Effects of perinatal asphyxia on cell survival, neuronal phenotype and neurite growth evaluated with organotypic triple cultures

The effect of perinatal asphyxia on brain development was studied with organotypic cultures from substantia nigra, neostriatum and neocortex. Asphyxia was induced by immersing foetuses-containing uterine horns removed from ready-to-deliver rats into a water bath for 20 min. Following asphyxia, the pups were nursed by a surrogate dam and sacrificed after three days for preparing organotypic cultures. Non-asphyxiated caesarean-delivered pups were used as controls. Morphological features and cell viability were recorded during in vitro development. At day in vitro (DIV) 24, the cultures were treated for immunocytochemistry using antibodies against the N-methyl-D-aspartate receptor subunit 1 (NR1) and tyrosine hydroxylase (TH). While in vitro survival was similar in cultures from both asphyxiated and control animals, differences were observed when the neuronal phenotype was assessed. Compared to controls, the total number of NR1-positive neurons in substantia nigra, as well as the number of secondary to higher level branching of TH-positive neurites from asphyxiated pups were decreased, illustrating the vulnerability of the dopaminergic systems to perinatal asphyxia.

[Microscopic polyangiitis in a patient with rheumatoid arthritis]

Rheumatoid arthritis (RA) is a systemic disorder that primary involves joints, although renal disease has also been associated it is not common that rapidly progressive glomerulonephritis (RPGN) appears. We report the case of a patient with nodular and aggressive RA who had an acut renal failure secondary to ANCA positive RPGN due to a Microscopic polyangiitis who was not responsive to steroids and cyclophosphamide therapy.

Comparison of two techniques to evaluate the acrosomal status of zona pellucida bound sperm in humans

In this work, we have compared two procedures that evaluate the acrosomal status of human sperm bound to the human zona pellucida. Motile sperm, selected by a Percoll gradient, were capacitated by incubation at 37 degrees C, 5% CO2, for 4.5 h, at 20 x 10(6) cells ml(-1). Then, the sperm were incubated with nonviable human oocytes for 10 min at 37 degrees C, 5% CO2. The oocytes with bound sperm were transferred to 500 microl phosphate-buffered saline (PBS) and washed to remove loosely bound sperm. The oocytes were then processed according to the procedures of Cross et al. (1986) or Liu & Baker (1996). In the Cross's procedure, the sperm were labelled while they were bound to the zona. In the Liu's procedure, the sperm were first dislodged from the zona into a droplet of PBS and labelled in there. Both procedures gave equivalent percentages of acrosome-reacted sperm. However, the total number of zona-bound sperm available for assessment with the procedure of Liu & Baker was greater than that of Cross et al. We suggest to use the former procedure to evaluate the acrosomal status of zona-bound sperm in humans. Moreover, this procedure also provided information about sperm ability to bind to the zona pellucida.

[Lung transplantation for pulmonary fibrosis: perioperative morbidity and mortality]

Lung transplantation has become a valid therapeutic option for patients with pulmonary fibrosis in terminal stage, and the number of such interventions has increased exponentially in recent years. We undertook a retrospective study of 46 pulmonary fibrosis patients who received lung transplants from 1992 through 2002 with the aim of describing the most common intra- and early postoperative complications in the recovery unit. We also aimed to analyze the impact of each complication on mortality during the study period. The most frequent complications during surgery were reperfusion syndrome (47.5%), hemodynamic instability (41%), arrhythmias (23.9%), and pulmonary hypertension (15%), with exitus secondary to reperfusion syndrome. The most common postoperative complications were infection (56.5%), reimplantation response (45.7%), and kidney failure (19.6%). Overall mortality during the study period was 23.9%. The following complications were statistically significant in the univariate analysis of the relation with mortality: reperfusion syndrome (p=0.039), reimplantation response (p=0.039), kidney failure (p=0.013), rejection (p=0.016), and sepsis (p<0.001). The only complication that remained significant in the multivariate analysis was sepsis (p<0.001). In spite of the considerable progress made, intra- and postoperative complications continue to be a real threat for the transplanted lung patient. Sepsis was the strongest predictor of poor prognosis in the early recovery period.

Safety of the concomitant use of caspofungin and cyclosporin A in patients with invasive fungal infections

Caspofungin, an echinocandin antifungal agent, is active against invasive Aspergillus and Candida infections. In a phase I study in healthy volunteers, mild transient increases in serum aminotransferases were observed with the concomitant administration of caspofungin and cyclosporin A (CsA). As a result, it is recommended that the concomitant use of the two drugs be limited to those settings with appropriate risk-benefit balance. We retrospectively assessed safety data in 14 patients with refractory invasive mycoses who were treated concomitantly with CsA and caspofungin before the drug was licensed in Spain. In all, 13 patients were adults (median age, 31.5 years; range, 14-67 years). The average duration of concomitant therapy was 15 days (range, 2-43 days). No clinically significant elevations of serum aminotransferases were observed, and no patient had concomitant therapy discontinued or interrupted due to a drug-related adverse event. In this study of a limited number of patients, the coadministration of caspofungin and CsA was generally well tolerated.

Caseinolysis in cheese by Enterobacteriaceae strains of dairy origin

AIMS

To study the effect of Enterobacteriaceae strains of dairy origin on caseins under cheese manufacture and ripening conditions.

METHODS AND RESULTS

Strains belonging to the genera Enterobacter, Escherichia, Hafnia and Serratia were isolated from fresh raw milk cheeses. Residual caseins in cheeses made from milk individually inoculated with 10 strains of Enterobacteriaceae were determined by capillary electrophoresis. Hierarchical cluster analysis of strains based on data of residual caseins grouped together strains from the same genus, excepting Hafnia strains, which were separated into two groups. Serratia was the most proteolytic genus in our study. Preferences for degradation of casein fractions differed among the four genera studied.

CONCLUSIONS

Enterobacteriaceae strains posses proteolytic systems active on all casein fractions under cheese manufacture and ripening conditions. The effects on caseins were similar for strains belonging to the same genus.

SIGNIFICANCE AND IMPACT OF THE STUDY

The presence of Enterobacteriaceae in cheeses may affect proteolysis during ripening. Assays of Enterobacteriaceae proteolytic activity on milk agar plates may underestimate their caseinolytic activity in cheese.

Perinatal asphyxia impairs connectivity and dopamine neurite branching in organotypic triple culture from rat substantia nigra, neostriatum and neocortex

The effect of perinatal asphyxia on brain development was studied with organotypic cultures from substantia nigra, neostriatum and neocortex. Asphyxia was induced by immersing foetuses-containing uterine horns removed from ready-to-deliver rats into a water bath for 20 min. Following asphyxia, the pups were nursed by a surrogate dam and sacrificed after 3 days to prepare organotypic cultures. Non-asphyxiated caesarean-delivered pups were used as controls. Morphological features were recorded during in vitro development. At day in vitro (DIV) 24, the cultures were treated for histochemistry using fast red for cell nucleus labelling and antibodies against tyrosine hydroxylase for dopaminergic neurons. Compared to controls, cultures from asphyxiated pups revealed a diminished integration quantified during 21 DIV. After immunocytochemistry and camera lucida reconstruction, tyrosine hydroxylase-positive neurons showed a decreased number of neurites from secondary and higher level branching, demonstrating a vulnerability of the dopaminergic systems after perinatal asphyxia.

Lung transplantation in patients with x-linked agammaglobulinemia

Lung transplantation is an established procedure to treat patients with end-stage lung disease. The criteria for recipient selection are broadening to include patients with congenital defects of the immune system, such as X-linked hypogammaglobulinemia (XLA). We report 2 cases of successful double lung transplantation in patients with XLA. The 2 men had developed bronchiectasis and end-stage lung disease despite early institution of intravenous immunoglobulin (IVIG) replacement therapy. Before transplantation, hypogammaglobulinemia was well controlled with IVIG in both patients. After transplantation, IVIG was administered every 48 hours during the first 10 days and then tapered slowly in the following weeks until returning to an every 3 weeks schedule. One patient has been followed up for 12 months and the other for 6 months. Lung function normalized in the first case and showed a restrictive pattern in the second one. Lung transplantation may be considered as a therapeutic option for patients with XLA and end-stage lung disease. Regular administration of IVIG overcomes the high risk of infections due to the severe immunodeficiency and the intensive immunosuppressive therapy.

Visceral leishmaniasis in lung transplantation

Infection by intracellular microorganisms with a special geographic distribution, such as Leishmania spp, has been reported in a limited number of patients undergoing solid-organ transplant (SOT). No cases of Leishmania spp infection in lung transplant patients were found in a review of the literature. In our series of 222 lung or heart and lung transplantations performed from February 1990 to October 2002, two cases of visceral leishmaniasis (VL) were diagnosed and treated with liposomal amphotericin B. All cases reported to date in transplant patients, including the ones discussed here, occurred in people living in or traveling to countries in the Mediterranean area. We therefore consider it advisable to include serological testing for latent infection due to Leishmania spp in pretransplantation screening for our geographical setting, despite the limited return of this strategy.

Cardiopulmonary transplantation: experience of a lung transplant group

Cardiopulmonary transplantation (CPT) is indicated for patients eligible for heart transplantation (HT) or lung transplantation (LT) who have severe concomitant lung or heart disease. Only 2 groups perform CPT in Spain. We report our experience with 18 CPTs representing 8.2% and 5% compared with LT (220) and HT (362), respectively, from February 13, 1990 to October 15, 2002. The mean time on a waiting list was 138 days. The current number of surviving patients is 7 (39%), with a mean follow-up of 602 days (range, 3 to 4627 days). They all remain asymptomatic with normal respiratory function in 4 patients. No cardiac graft rejection has been detected. Two patients experienced sustained gastroparesis during the first year with spontaneous resolution. Death occurred within the first 3 months in 9 patients. These outcomes contrast with the early mortality associated with LT and HT in our series, namely 10.6% and 11%, respectively. The different causes of death were as follows: sepsis and multiorgan failure in 5 patients, hemorrhagic shock in 3 patients, and suture dehiscence and fungal aortic perforation in 1 patient. Late mortalities were recorded in 2 cases. Overall patient survival in our series is lower than that reported by the International Registry (IR), with an early mortality rate of 50% (30% IR). Nevertheless, our survival rate at 10 years after transplantation is 30% (26% IR). We conclude that CPT should be considered despite the greater early morbidity and mortality.

Hydrophilic and hydrophobic peptides produced in cheese by wild Lactococcus lactis strains

AIMS

To study the production of hydrophilic and hydrophobic peptides in cheese by 32 wild Lactococcus lactis strains of different RAPD patterns and to compare them with the peptides produced by lactococcal cells incubated with whole casein.

METHOD AND RESULTS

Chromatograms of peptides from cheeses made using each strain as single starter culture were divided into five regions, and strains were classified in three groups by hierarchical cluster analysis of region areas. Thirty out of the 32 wild L. lactis strains produced higher levels of hydrophobic peptides in cheese than on whole casein.

CONCLUSIONS

Cheese was a more favourable substrate than whole casein for hydrophobic peptide formation by L. lactis strains.

SIGNIFICANCE AND IMPACT OF THE STUDY

New strains of lactococci should be screened for bitterness under cheese conditions, as the formation of hydrophobic peptides may be underestimated in assays with casein as substrate.

MR imaging of myocardial haematoma after blunt chest injury

Myocardial contusion after a chest trauma is a frequently under-diagnosed injury. We report two cases of myocardial contusion in which MR imaging, thanks to its contrast capability, was able to assess the presence of a haematoma and in one case to demonstrate the recovery of the lesion.

Corticosterone differentially regulates bax, bcl-2 and bcl-x mRNA levels in the rat hippocampus

It has previously been shown that adrenalectomy (ADX) produces apoptosis in the granule cell of the dentate gyrus (DG), and that this effect is prevented by corticosterone replacement. Thus, we have investigated how this phenomenon takes place in rat hippocampus using in situ hybridization. The expression of the pro-apoptotic gene bax was measured in the pyramidal cell fields and in the DG. After 5 days of ADX, there was a significant increase in bax mRNA levels in the suprapyramidal layer of the DG, an effect prevented by corticosterone replacement. The mRNA of the anti-apoptotic bcl-2 gene was expressed in CA3 and DG. ADX increased bcl-2 mRNA levels, but only in the suprapyramidal layer of the DG, an effect that was prevented by corticosterone administration. It is concluded that the up-regulation of bax may explain the apoptosis observed in DG after ADX, while the bcl-2 induction may correspond to a compensatory mechanism protecting the cells from death.