Discussion of interesting or befuddling cases related to pulmonary and critical care medicine.
Tuesday, August 09, 2005
QQ
Just a quick question while we are all mulling over Carlos' post; if a patient had resection of some RUL aspergilloma and he is going to get a renal transplant (thus immunosuppressed), do you give that patient prophylactic itraconazole after the kidney transplant?
Last time I had a Pt with a renal Txp and aspergillus in the lung we kept him on long term suppression with itraconazole. The case was a little different from yours though: our patient developed pulmonary aspergillosis while on immunosuppression. Unfortunately his graft failed and he was actually off immunosuppression while being re-listed for Txp... so his pulmonary status improved and since he was no longer immunosuppressed we actually stopped the itraconazole. In your case he already has some non-specific defficiency that predisposed him to the aspergillus (likely just structural lung dz) and he will get even more suppressed after the Txp so he might need lifelong (or graftlong) suppression.
I disagree with CEOB. This patient may have had aspergillus in his sinuses at some time and it ultimately made its way to a structural lung abnormality.
Presuming that you have successfully removed the intrinisic lung disease (and he has no residual cavities that could support aspergillus growth, I would not give itraconazole.
However, if you still have any intrinisic lung disease, he needs itra.
So... you are saying that if all the patient had was a single cavity that got colonized with no other abnormalities you would not give itra but if there is any residual dz similar to what led to the aspergilloma in the first place you would?
For what it's worth, I decided to get an HRCT (his lung function is good after the resection). If that shows evidence to suggest some left-over aspergillus, the rec would be to give the prophylaxis because the risk of that drug is more tolerable than the risk of getting reactivation and then having to treat active aspergillus (if he survives as all). If the HRCT is pristine, one might argue to STILL give the prophylctic antifungal but at least then the argument could be made to hold off...
Yes, if it was a single cavity in the lung that had aspergillus in it (and presumably it was removed), I would not give itra. Think of all of the patients with diabetes and aspergillus in their sinuses (a cavity) who get renal transplants. To the best of my knowledge, the nephrologists do not do sinus imaging before transplanting a patient with diabetes.
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Last time I had a Pt with a renal Txp and aspergillus in the lung we kept him on long term suppression with itraconazole. The case was a little different from yours though: our patient developed pulmonary aspergillosis while on immunosuppression. Unfortunately his graft failed and he was actually off immunosuppression while being re-listed for Txp... so his pulmonary status improved and since he was no longer immunosuppressed we actually stopped the itraconazole.
In your case he already has some non-specific defficiency that predisposed him to the aspergillus (likely just structural lung dz) and he will get even more suppressed after the Txp so he might need lifelong (or graftlong) suppression.
I disagree with CEOB. This patient may have had aspergillus in his sinuses at some time and it ultimately made its way to a structural lung abnormality.
Presuming that you have successfully removed the intrinisic lung disease (and he has no residual cavities that could support aspergillus growth, I would not give itraconazole.
However, if you still have any intrinisic lung disease, he needs itra.
So... you are saying that if all the patient had was a single cavity that got colonized with no other abnormalities you would not give itra but if there is any residual dz similar to what led to the aspergilloma in the first place you would?
For what it's worth, I decided to get an HRCT (his lung function is good after the resection). If that shows evidence to suggest some left-over aspergillus, the rec would be to give the prophylaxis because the risk of that drug is more tolerable than the risk of getting reactivation and then having to treat active aspergillus (if he survives as all). If the HRCT is pristine, one might argue to STILL give the prophylctic antifungal but at least then the argument could be made to hold off...
Yes, if it was a single cavity in the lung that had aspergillus in it (and presumably it was removed), I would not give itra.
Think of all of the patients with diabetes and aspergillus in their sinuses (a cavity) who get renal transplants. To the best of my knowledge, the nephrologists do not do sinus imaging before transplanting a patient with diabetes.
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