CNS infections in patients with hematological disorders (including allogeneic stem-cell transplantation)-Guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO)

Diagnosis of CNS infections remains a great challenge in patients with hematological disorders since symptoms might both be masked and be mimicked by other conditions such as metabolic disturbances or consequences from antineoplastic treatment. Thus, awareness of this complication is crucial and any suspicion of a CNS infection should lead to timely and adequate diagnostics and treatment to improve the outcome in this population.

Infections of the central nervous system (CNS) are infrequently diagnosed in immunocompetent patients, but they do occur in a significant proportion of patients with hematological disorders. In particular, patients undergoing allogeneic hematopoietic stem-cell transplantation carry a high risk for CNS infections of up to 15%. Fungi and Toxoplasma gondii are the predominant causative agents. The diagnosis of CNS infections is based on neuroimaging, cerebrospinal fluid examination and biopsy of suspicious lesions in selected patients. However, identification of CNS infections in immunocompromised patients could represent a major challenge since metabolic disturbances, side-effects of antineoplastic or immunosuppressive drugs and CNS involvement of the underlying hematological disorder may mimic symptoms of a CNS infection. The prognosis of CNS infections is generally poor in these patients, albeit the introduction of novel substances (e.g. voriconazole) has improved the outcome in distinct patient subgroups. This guideline has been developed by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) with the contribution of a panel of 14 experts certified in internal medicine, hematology/oncology, infectious diseases, intensive care, neurology and neuroradiology. Grades of recommendation and levels of evidence were categorized by using novel criteria, as recently published by the European Society of Clinical Microbiology and Infectious Diseases.

Incidence of bleeding in 8172 percutaneous ultrasound-guided intraabdominal diagnostic and therapeutic interventions - results of the prospective multicenter DEGUM interventional ultrasound study (PIUS study)

PURPOSE

To analyse the incidence of bleeding after percutaneous ultrasound guided diagnostic and therapeutic intraabdominal interventions in a prospective multicentre study (DEGUM percutaneous interventional ultrasound study).

MATERIALS AND METHODS

Within a time period of 2 years diagnostic and therapeutic intraabdominal interventions (with the exclusion of ascites paracentesis) performed percutaneously under continuous ultrasound (US) guidance were prospectively assessed using a pseudonymized standardized web site entry form. Number and type of intervention, operator experience, patient characteristics, medication, lab data as well as technical aspects of the procedure and bleeding complications were analysed according to the interventional radiology standards.

RESULTS

8172 US-guided intraabdominal interventions (liver n = 5903; pancreas n = 501, kidney n = 434, lymph node = 272, biliary system n = 153, spleen n = 63, other abdominal organs and extra-organic targets n = 999) were analysed in 30 hospitals. The majority were diagnostic biopsies including 1780 liver parenchyma, 3400 focal liver lesions and 404 pancreatic lesions. 7525 interventions (92.1 %) were performed in hospitalized patients (mean age 62.6 years). Most operators were highly experienced in US-guided interventions (> 500 interventions prior to the study n = 5729; 70.1 %). Sedation was administered in 1131 patients (13.8 %). Needle diameter was ≥ 1 mm in 7162 punctures (87.9 %) with main focus on core needle biopsies (18 G, n = 4185). Clinically relevant bleeding complications with need of transfusion (0.4 %), surgical bleeding control (0.1 %) and radiological coiling (0.05 %) were very rare. Bleeding complications with fatal outcome occurred in four patients (0.05 %). The frequency of major bleeding complications was significantly higher in patients with an INR > 1.5 (p < 0.001) and patients taking a medication potentially interfering with platelet function or plasmatic coagulation (p < 0.0333).

CONCLUSION

This prospective multicentre study confirms the broad spectrum of percutaneous US-guided intraabdominal interventions. However diagnostic liver biopsies dominate with the use of core needle biopsies (18 G). Percutaneous US-guided interventions performed by experienced sonographers are associated with a low bleeding risk. Major bleeding complications are very rare. A pre-interventional INR < 1.5 and individual medication risk assessment are recommended.

Endophthalmitis as primary clinical manifestation of fatal fusariosis in an allogeneic stem cell recipient

The occurrence of infections due to previously rare opportunistic pathogens is increasing despite the use of novel treatment strategies for immunocompromised patients. Here, we report the case of a patient presenting with fever, muscle pain, and bilateral endophthalmitis after allogeneic hematopoietic stem cell transplantation. Fusarium solani was isolated from peripheral blood samples and identified as the cause of gradual bilateral vision loss, despite appropriate antifungal prophylaxis, and therapy including vitrectomy and intraocular instillation of antifungal agents. The patient became comatose; basal meningitis involving both optic nerves was suspected based on magnetic resonance tomography. The patient died 8 days later due to septic multi-organ failure. Autopsy revealed that both kidneys, but no other organs, were infiltrated by Fusarium. No fungus was found in cerebral tissues or cerebrospinal fluid. Our case demonstrates some of the typical clinical features of systemic fusariosis and its potentially fatal outcome. The clinical observations reported here may help clinicians caring for immunocompromised patients to accelerate diagnosis and initiate treatment early at the onset of this fatal complication, and highlight the urgent need for interdisciplinary management of invasive fusariosis.

Different doses of micafungin for prophylaxis of invasive fungal diseases in hemato-oncological high-risk patients: a web-based non-interventional trial in four large university hospitals in Germany

INTRODUCTION

Treatment indications of new antifungals in clinical practice often deviate from the strict criteria used in controlled clinical trials. Under routine clinical conditions, beneficial and adverse effects, not previously described in clinical trials may be observed. The aim of this study was to describe customary prescription and treatment strategies of micafungin (MCFG).

METHODS

A registry was set up on www.ClinicalSurveys.net and physicians were invited to provide retrospective information on cases they had treated with MCFG. Documentation comprised demographic information, underlying disease, effectiveness, safety, and tolerability of MCFG.

RESULTS

A total of 125 episodes of patients hospitalized between September 2009 and February 2012 were documented, of which 7 had to be excluded because of incomplete documentation. The most common risk factors of patients were hematological malignancy (n = 116, 98.3%) and antibiotic treatment >3 days (n = 115, 97.5%). MCFG was administered as prophylaxis in 106 (89.9%) patients. Median duration of MCFG application as prophylaxis was 21 days (range: 3-78); 53 of the patients (50%) received a dose of 50 mg, while the other 53 (50%) received 100 mg/day. For the different doses, prophylactic outcome was rated as success in 42 (79.2%) vs. 52 (98.1%; P = 0.004) patients. Fifty-five patients (51.9%) were treated with posaconazole before initiation of MCFG. Four patients (7.5%) developed a proven invasive fungal disease (IFD) while being treated with 50 mg MCFG, compared to no patient treated with 100 mg (P = 0.118). At the end of MCFG prophylaxis, 24 (22.6%) patients were switched to fluconazole and 64 (60.3%) patients to posaconazole.

CONCLUSION

Our study shows clinical effectiveness of MCFG prophylaxis with low rates of breakthrough fungal infections. In most cases, MCFG was part of a multi-modal antifungal prophylactic strategy. Investigators reported fewer proven IFDs in patients receiving therapeutic doses of MCFG as prophylaxis.

New techniques for high-temperature melting measurements in volatile refractory materials via laser surface heating

An original technique for the measurement of high-temperature phase transitions was implemented based on a laser-heating method, enabling chemically unstable, refractory materials to be melted under controlled conditions. This technique includes two independent but correlated methods: In the first, fast multichannel pyrometry is employed to measure thermograms and spectral emissivity; in the second, a low-power probe laser beam is used for the detection of reflectivity changes induced by phase transitions on the sample surface. The experiments are carried out under medium ( approximately 10(2) kPa) or high ( approximately 10(2) MPa) inert-gas pressures in order to kinetically suppress evaporation in volatile or chemically instable samples. Two models for the simulation of the laser-heating pulses are as well introduced. Some results are presented about the successful application of this technique to the study of the melting behavior of oxides such as UO(2+x), ZrO(2), and their mixed oxides. The method can be extended to a broad class of refractory materials.

[Lung ultrasound in COVID-19]

Die medizinische Versorgung von Patienten, die im Zusammenhang mit der pandemischen Coronaviruserkrankung 2019 („coronavirus disease 2019“, COVID-19) erkrankt sind, stellt für die staatlichen Gesundheitssysteme weltweit eine große Herausforderung dar. Das Virus mit dem Namen „severe acute respiratory syndrome coronavirus 2“ (SARS-CoV-2) zeigt eine hohe Organspezifität zu den unteren Atemwegen. Da bislang weder eine wirksame Therapie noch Impfung gegen das Virus existieren, kommt der diagnostischen Früherkennung eine große Bedeutung zu. Durch den spezifischen Aspekt der überwiegend im peripheren Lungenparenchym beginnenden Infektion ist die Lungensonographie als bildgebende Diagnostikmethode geeignet, Verdachtsfälle bereits im Frühstadium der Erkrankung als solche zu identifizieren. Serielle Ultraschalluntersuchungen an Patienten mit bestätigter Infektion können bettseitig und zeitnah Veränderungen im betroffenen Lungengewebe nachweisen. Dieser Artikel fasst das diagnostische Potenzial der Lungensonographie im Hinblick auf Screening und therapeutische Entscheidungsfindung bei Patienten mit vermuteter oder bestätigter SARS-CoV-2-Pneumonie zusammen.

[Inflammatory myofibroblastic tumour (so-called pseudotumour) of the hepatobiliary system]

The purpose of this report is to describe the ultrasonographic features of hepatic inflammatory myofibroblastic tumour (IMT). This tumour presented as an area of periportal soft-tissue infiltration. Because periportal infiltration is a common feature in both IMT and other malignant tumours of the hepatic portal, histological examination should be considered before final diagnosis and treatment.

[Transabdominal sonography of the gastrointestinal tract: what is the clinical value?]

Die transabdominelle Sonographie des Magen-Darm-Traktes hat in geübten Händen eine vergleichbare diagnostische Aussagekraft wie die CT. Beim Nachweis von Abszessen und Perforationen ist die Ultraschalluntersuchung der CT unterlegen. Bei schwierigen Untersuchungsbedingungen (Adipositas, Meteorismus, Peritonismus) und bei unerfahrenen Untersuchern kann die Wertigkeit der Sonographie des Magen-Darm Traktes deutlich eingeschränkt sein.

Low trough levels of tipranavir in a combination antiretroviral therapy of tipranavir/ritonavir and tenofovir require therapeutic drug monitoring

The new non-peptidic protease inhibitor tipranavir is used boosted with ritonavir in a 500/200 mg bid scheme. Multiple drug interactions are described for both drugs because of their different action in CYP450 3A4 and p-glycoprotein. In this retrospective analysis of 22 patients during therapy with tipranavir/ritonavir (TPV) 500 mg/200 mg bid, we found significantly decreased TPV-trough levels in combination with tenofovir (15.32+/-5.22 microg/ml) in comparison to TPV trough levels without tenofovir (20.21+/-14.87 microg/ml). Therapeutic drug monitoring of TPV is recommended.

[Patient with COPD after allogeneic hematopoietic stem cell transplantation with cough and subfebrile temperature]

HISTORY AND ADMISSION FINDINGS

A 53-year-old male presents with progressive cough and subfebrile temperatures with a history of COPD and post one-year allogeneic hematopoietic stem cell transplantation.

EXAMINATIONS

No pathogenic agent was identified in virological and microbiological diagnostic testings of sputum. At bronchoscopy a half peanut was retrieved from the right main bronchus.

TREATMENT AND COURSE

After recovery of the peanut the patient's symptoms immediately improved.

CONCLUSIONS

Even in adults, with high risk of infectious pneumonia a foreign body aspiration should be considered if pulmonary symptoms worsen.

[Burns following magnetic resonance tomography study]

Skin burns associated with magnetic resonance imaging (MRI) examinations have been published. We describe the case of a 54-year-old patient with third-degree burns after MRI of the abdomen and pelvis on a 1.5 T MR system.