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Poststernotomy aspergillosis: successful treatment with voriconazole, surgical debridement and vacuum-assisted closure therapy.

Siciliano RF, Waisberg DR, Samano MN, Leite PF, Tuma Júnior P, Barreiro GC, Strabelli TM - Clinics (Sao Paulo) (2012)

View Article: PubMed Central - PubMed

Affiliation: Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brazil. rinaldo_focaccia@uol.com.br

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After 3 months of voriconazole therapy, plasma C-reactive protein normalized, and Technetium-99 m/Gallium-67 scintillography showed no evidence of osteomyelitis... Liposomal amphotericin B was considered the most suitable clinical treatment for invasive aspergillosis until recently... Another potential option is the new formulation of oral itraconazole solution, which penetrates bone tissue more effectively and can be used as a prolonged outpatient treatment... The adverse effects reported include transient visual disturbances, hepatotoxicity, and severe photosensitivity rash, which must be taken into consideration when long courses of therapy are required, as in the case of osteomyelitis... Most studies have reported mild to moderate adverse effects, which did not lead to the discontinuation of therapy... In a case series of 12 patients with Aspergillus spp. osteomyelitis, 63.6% responded to antifungal combinations including voriconazole... Mouas et al. reviewed the cases of 20 patients with bone aspergillosis treated with voriconazole (in 2 cases as first-line therapy and in 18 cases as salvage therapy because treatment had failed or the patient did not tolerate the previous antifungal therapy) and found that there was a satisfactory response in 55% of patients... Regarding chest wounds, most algorithms recommend its use following surgical debridement, as it allows for wound drainage, granulation stimulation, increased tissue blood flow, chest wall stabilization, chest cavity isolation to prevent contamination, and the maintenance of a moist environment... Consequently, the rate of reinfection and the length of the patient's hospital stay are decreased... In our case, however, it was possible to perform primary closure... In conclusion, invasive bone aspergillosis should be considered when dealing with slowly progressive chest wall wound infections following cardiac surgery, even in immunocompetent patients.

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A) Bilateral infection in the 3rd to 8th costal cartilages and ribs. B) 3rd to 8th bilateral costal cartilage removal. C) Second bilateral debridement of the 6th ribs on the 4th post-operative day. D) Final apperance of the wound with insertion of a Portovac® tube.
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f1-cln_67p297: A) Bilateral infection in the 3rd to 8th costal cartilages and ribs. B) 3rd to 8th bilateral costal cartilage removal. C) Second bilateral debridement of the 6th ribs on the 4th post-operative day. D) Final apperance of the wound with insertion of a Portovac® tube.

Mentions: The patient underwent aggressive surgical debridement by thoracic and plastic surgeons with the removal of steel stitches, which revealed bilateral infection in the 3rd to 8th costal cartilages (Figure 1A), which were partially removed (Figure 1B), and vacuum-assisted closure (VAC) was used. The subject remained on VAC until new surgical debridement was performed bilaterally on the 6th ribs four days later (Figure 1C). The VAC device was removed, a Portovac® tube was inserted, and the wound was closed primarily (Figure 1D). The patient had a favorable clinical evolution, without signs of systemic disseminated infection. Cartilaginous-bone tissue biopsies from the first and second surgical procedures showed Aspergillus osteomyelitis. The culture from the surgically removed sternal bone demonstrated the presence of Aspergillus spp. Treatment with a combination of vancomycin and ciprofloxacin was discontinued, and intravenous voriconazole (4 mg/kg per dose twice daily) was started six days after the first surgery. The Portovac® tube was removed three days later, and the patient was discharged on the 18th day after the first surgical procedure. Intravenous voriconazole therapy was continued for a total of 42 days, when it was changed to oral capsules for 4 more months. After 3 months of voriconazole therapy, plasma C-reactive protein normalized, and Technetium-99 m/Gallium-67 scintillography showed no evidence of osteomyelitis. The patient currently remains very well, and the sternal wounds have healed completely.


Poststernotomy aspergillosis: successful treatment with voriconazole, surgical debridement and vacuum-assisted closure therapy.

Siciliano RF, Waisberg DR, Samano MN, Leite PF, Tuma Júnior P, Barreiro GC, Strabelli TM - Clinics (Sao Paulo) (2012)

A) Bilateral infection in the 3rd to 8th costal cartilages and ribs. B) 3rd to 8th bilateral costal cartilage removal. C) Second bilateral debridement of the 6th ribs on the 4th post-operative day. D) Final apperance of the wound with insertion of a Portovac® tube.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3297043&req=5

f1-cln_67p297: A) Bilateral infection in the 3rd to 8th costal cartilages and ribs. B) 3rd to 8th bilateral costal cartilage removal. C) Second bilateral debridement of the 6th ribs on the 4th post-operative day. D) Final apperance of the wound with insertion of a Portovac® tube.
Mentions: The patient underwent aggressive surgical debridement by thoracic and plastic surgeons with the removal of steel stitches, which revealed bilateral infection in the 3rd to 8th costal cartilages (Figure 1A), which were partially removed (Figure 1B), and vacuum-assisted closure (VAC) was used. The subject remained on VAC until new surgical debridement was performed bilaterally on the 6th ribs four days later (Figure 1C). The VAC device was removed, a Portovac® tube was inserted, and the wound was closed primarily (Figure 1D). The patient had a favorable clinical evolution, without signs of systemic disseminated infection. Cartilaginous-bone tissue biopsies from the first and second surgical procedures showed Aspergillus osteomyelitis. The culture from the surgically removed sternal bone demonstrated the presence of Aspergillus spp. Treatment with a combination of vancomycin and ciprofloxacin was discontinued, and intravenous voriconazole (4 mg/kg per dose twice daily) was started six days after the first surgery. The Portovac® tube was removed three days later, and the patient was discharged on the 18th day after the first surgical procedure. Intravenous voriconazole therapy was continued for a total of 42 days, when it was changed to oral capsules for 4 more months. After 3 months of voriconazole therapy, plasma C-reactive protein normalized, and Technetium-99 m/Gallium-67 scintillography showed no evidence of osteomyelitis. The patient currently remains very well, and the sternal wounds have healed completely.

View Article: PubMed Central - PubMed

Affiliation: Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brazil. rinaldo_focaccia@uol.com.br

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

After 3 months of voriconazole therapy, plasma C-reactive protein normalized, and Technetium-99 m/Gallium-67 scintillography showed no evidence of osteomyelitis... Liposomal amphotericin B was considered the most suitable clinical treatment for invasive aspergillosis until recently... Another potential option is the new formulation of oral itraconazole solution, which penetrates bone tissue more effectively and can be used as a prolonged outpatient treatment... The adverse effects reported include transient visual disturbances, hepatotoxicity, and severe photosensitivity rash, which must be taken into consideration when long courses of therapy are required, as in the case of osteomyelitis... Most studies have reported mild to moderate adverse effects, which did not lead to the discontinuation of therapy... In a case series of 12 patients with Aspergillus spp. osteomyelitis, 63.6% responded to antifungal combinations including voriconazole... Mouas et al. reviewed the cases of 20 patients with bone aspergillosis treated with voriconazole (in 2 cases as first-line therapy and in 18 cases as salvage therapy because treatment had failed or the patient did not tolerate the previous antifungal therapy) and found that there was a satisfactory response in 55% of patients... Regarding chest wounds, most algorithms recommend its use following surgical debridement, as it allows for wound drainage, granulation stimulation, increased tissue blood flow, chest wall stabilization, chest cavity isolation to prevent contamination, and the maintenance of a moist environment... Consequently, the rate of reinfection and the length of the patient's hospital stay are decreased... In our case, however, it was possible to perform primary closure... In conclusion, invasive bone aspergillosis should be considered when dealing with slowly progressive chest wall wound infections following cardiac surgery, even in immunocompetent patients.

Show MeSH
Related in: MedlinePlus