Selby R, Ramirez C B, Singh R, Kleopoulos I, Kusne S, Starzl T E, Fung J
Department of Surgery, University of Pittsburgh School of Medicine, Pa, USA.
Arch Surg. 1997 Mar;132(3):304-10. doi: 10.1001/archsurg.1997.01430270090019.
To determine the incidence, clinical presentation, and outcome and confounding factors associated with the development of a brain abscess in solid organ transplant recipients.
A 14-year retrospective survey.
A single, multiorgan, academic transplantation center.
A total of 2380 liver transplant recipients, 1650 kidney transplant recipients, and 598 heart, heart-lung, or lung transplant recipients of all ages (pediatric and adult) were included. All patients were given cyclosporine-based immunosuppression during this period.
A brain abscess was determined to be present it there was histological and/or microbiological confirmation of a brain lesion seen by a computed tomographic scan. A brain abscess was considered suspicious if radiographic findings were seen in the clinical setting of neurologic symptoms and fever without histological or microbiological confirmation.
A brain abscess developed in a total of 28 patients (0.61%) of the total study population. The frequency of brain abscess according to organ type was as follows: 0.63%, liver; 0.36%, kidney; and 1.17%, heart and heart-lung. The overall mortality was 86%. Complicating factors associated with fungal (Candida and Aspergillus sp) abscess formation included major subsequent operations, retransplantations, antirejection therapy, associated bacteremia or viremia, and multiorgan failure. The lung was the primary site of dissemination in 18 patients. Low-dose prophylactic amphotericin was ineffective in preventing a fungal brain abscess in 10 high-risk patients. Because of the ineffective therapy and the deadly nature of established fungal abscesses, full-dose antifungal therapy and reduced immunosuppression were warranted on identification of a high-risk clinical setting. Nonfungal abscesses (Nocardia and Toxoplasma sp) occurred in healthy graft recipients long after transplantation. The existing medical therapy is usually effective in these patients, provided that rapid tissue diagnosis is established.
The epidemiological features of brain abscess formation after solid organ transplantation suggest 2 populations of patients exist that differ in timing, clinical setting, and response to therapy. For the chronically immunosuppressed outpatient, an established abscess should be empirically treated with sulfonamides until tissue diagnosis is confirmed. On the other hand, the acutely immunosuppressed posttransplant recipient, with defined risk factors, should receive full-dose therapy with amphotericin B and concomitantly lowered immunosuppression.
确定实体器官移植受者发生脑脓肿的发生率、临床表现、结局及相关混杂因素。
一项为期14年的回顾性调查。
一个单一的多器官学术移植中心。
纳入了总共2380例肝移植受者、1650例肾移植受者以及598例各年龄段（儿童和成人）的心脏、心肺或肺移植受者。在此期间，所有患者均接受以环孢素为基础的免疫抑制治疗。
如果计算机断层扫描显示的脑病变有组织学和/或微生物学证实，则确定存在脑脓肿。如果在有神经症状和发热的临床背景下出现影像学表现但无组织学或微生物学证实时，则脑脓肿被视为可疑。
在整个研究人群中，共有28例患者（0.61%）发生脑脓肿。根据器官类型，脑脓肿的发生率如下：肝移植受者为0.63%；肾移植受者为0.36%；心脏和心肺移植受者为1.17%。总体死亡率为86%。与真菌（念珠菌和曲霉菌属）性脓肿形成相关的复杂因素包括随后的大手术、再次移植、抗排斥治疗、相关的菌血症或病毒血症以及多器官功能衰竭。肺是18例患者的主要播散部位。低剂量预防性两性霉素B对10例高危患者预防真菌性脑脓肿无效。由于治疗无效以及已形成的真菌性脓肿具有致命性，因此在确定高危临床背景后，应给予全剂量抗真菌治疗并降低免疫抑制水平。非真菌性脓肿（诺卡菌和弓形虫属）发生在移植后很长时间的健康移植受者中。只要能迅速进行组织诊断，现有的药物治疗通常对这些患者有效。
实体器官移植后脑脓肿形成的流行病学特征表明存在两类患者，其在发病时间、临床背景及对治疗的反应方面有所不同。对于长期免疫抑制的门诊患者，在组织诊断得到证实之前，应经验性地用磺胺类药物治疗已形成的脓肿。另一方面，对于有明确危险因素的急性免疫抑制的移植后受者，应接受两性霉素B全剂量治疗，并同时降低免疫抑制水平。
