COMPLICATIONS - INFECTIONS

A.M. Concejero¹, C. Chen², H. Lu¹, H. Eng¹, J. Liu¹, C. Wang¹, S. Wang¹, C. Yong^1
1Liver Transplant Program, Department Of Surgery, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Kaohsiung/TAIWAN, ²Liver Transplant Program, Chang Gung Memorial Hospital, Kaohsiung/TAIWAN

Body: Objective: Granulomatous infections, particularly tuberculosis and cryptococcosis, carry a significant morbidity after liver transplantation among end-stage liver disease patients due to its potential lethal disseminated form of disease brought by immunosuppression and toxicity of drugs used in treatment. Our objective is to review our approach in the management of liver transplant candidates with granulomatous infections. Methods: From June 1994-September 2009, 326 primary adult living donor liver transplants were performed. The clinical records, chest radiographs, CT scan findings, immunologic antigens, and pathology were reviewed. Twenty-three (23, 7%) patients were diagnosed with granulomatous infections. Results: All patients were males. The mean age was 56 years. Six (6) were diagnosed with pulmonary cryptococcosis, 8 with pulmonary tuberculosis, 1 with gastrointestinal miliary tuberculosis, and 8 with granulomatous pulmonary nodule of undetermined etiology. All were asymptomatic as to organ involvement. Pulmonary nodules were the most frequent radiological abnormality. Four cryptoccocosis patients presented with solitary pulmonary nodules and were resected, 1 presented with both pulmonary nodule and pleural effusion where the nodule was resected, and 1 presented with pleural effusion. Of the 8 pulmonary nodules diagnosed with pulmonary tuberculosis, 1 nodule was resected and the rest were treated medically. The gastrointestinal military tuberculosis patient did not show any abnormality both on chest x-ray and CT scan. On laparotomy, at the time of transplant, the bowels were noted to be studded with miliary-like nodules and histologic confirmation of these nodules showed tuberculosis. The transplant operation in this patient was aborted. Of the 8 granulomatous nodules classified as undetermined etiology, 4 were calcified granulomas and 4 were small (<0.5 cm) to be considered significant. All cryptococcosis patients received fluconazole for 2 weeks before transplant and continued for another 6 months postransplant. All pulmonary tuberculosis patients received a modified anti-tuberculous regimen consisting of moxifloxacin, pyrazinamide, isoniazid, and ethambutol for 6 months to 1 year. All 8 patients with granulomatous nodules of undetermined etiology did not receive any other treatment. There was no mortality among transplanted patients. Recurrent infection was not seen in any patient after a minimum of 6 months follow-up posttransplant. Conclusion: Adequate antibiotic treatment of active granulomatous infections before and after liver transplant results to effective control of the disease and avoids fatal dissemination.

Disclosure: All authors have declared no conflicts of interest.