One Year Incidence of Infection in Pediatric Intestine Transplantation

Background: This study reports the infection rate, location of infection, and pathogen causing bacterial, fungal, or viral infections in intestine transplant recipients at a pediatric transplant center. Methods: Records from a pediatric center were reviewed for patients receiving an intestine transplant. Positive cultures and pathology reports were used to diagnose bacterial, fungal, and viral infections and also to determine location and infectious agent. Risk for infection was assessed based on liver or colon inclusion, and immunosuppression induction, as part of the intestine transplant. Results: During the study period 52 intestine transplants were performed on 46 patients. Bacterial, fungal, and viral infection rates were 90%, 25%, and 75%, respectively. Enterococcus (non-vancomycin resistant enterococci (VRE)) species were the most common pathogens and were isolated from 52% of patients. VRE was present in 12% of transplant recipients. Candida species were the most common fungal pathogens (23% of patients). Respiratory viral infections were common (44%) and cytomegalovirus infection rate was 17%. Common sites of infection were bloodstream, urinary, and upper respiratory tract. Colon and liver inclusion in the transplant graft was not associated with increased risk of infection, nor was addition of rituximab to the immunosuppression induction protocol. Conclusion: Post-intestine transplant infections are ubiquitious in the pediatric population, including high rates of infection from bacterial, viral and fungal sources. Inclusion of the liver and/or colon as a component of the transplant graft did not appear to greatly impact the infectious risk. Adding rituximab to the immunosuppression induction protocol did not impact on infectious risk

Post‐intestine transplant graft‐versus‐host disease: Associated with inclusion of a liver graft and with a high mortality risk

Introduction This study reports the incidence, anatomic location, and outcomes of graft‐versus‐host disease (GVHD) at a single active intestine transplant center. Methods Records were reviewed for all patients receiving an intestine transplant from 2003 to 2015. Pathology reports and pharmacy records were reviewed to establish the diagnosis, location, and therapeutic interventions for GVHD. Results A total of 236 intestine transplants were performed during the study period, with 37 patients (16%) developing GVHD. The median time to onset of disease was 83 days, with 89% of affected patients diagnosed in the first year post‐transplant. Mortality for affected patients was 54% in the one‐year after GVHD diagnosis. Skin lesions were the most common manifestation of GVHD. Other sites of disease included lungs, bone marrow, oral mucosa, large intestine, and brain. The incidence of GVHD was 16% in adult patients, and slightly lower in pediatric recipients (13%). In adults, increasing graft volume (isolated versus multi‐organ) and liver inclusion were associated with increasing risk of GVHD, though this was not seen in pediatric patients. Conclusion Overall, 16% of intestine transplant recipients developed GVHD. GVHD is associated with high mortality, and disease in the lungs, brain, and bone marrow was universally fatal

Mechanical Thrombectomy for Sequential Bilateral Middle Cerebral Artery Occlusions in a Patient With Recurrent Cryptogenic Strokes: A Case Report

Recurrent sequential mechanical thrombectomy for cryptogenic large vessel occlusion (LVO) can lead to excellent clinical outcome. A 68-year-old right-handed male presented with an acute proximal right middle cerebral artery (MCA) ischemic syndrome and underwent successful revascularization by mechanical thrombectomy with normal functional recovery. He was treated with dual antiplatelet therapy for 2 months following discharge, however later discontinued clopidogrel due to side effects. He then developed a recurrent, contralateral MCA occlusion 16 months later and once again received emergent endovascular reperfusion therapy with excellent neurological outcome. He has remained on off-label empiric oral anticoagulation since and has not had recurrent stroke nor evidence of cerebral ischemia. Favorable clinical outcomes can be achieved in patients despite recurrent LVO who underwent emergent mechanical thrombectomy. Optimal antithrombotic secondary stroke prevention strategies following embolic stroke of unknown source remains uncertain as recent evidence does not support rivaroxaban or dabigatran over aspirin. The benefit of apixaban over aspirin for the prevention of recurrent cerebral ischemia is under current investigation