INVASIVE ASPERGILLOSIS IN CHILDREN AFTER LIVER TRANSPLANTATION -THE SINGLE CENTER EXPERIENCE:

P830 Aims: Invasive fungal infections are serious complication in liver transplant (Ltx) recipients, especially Aspergillus sp. infection in immunocompromised patients is associated with highest mortality rate. We retrospectively assessed the cases of invasive Aspergillosis (IA) in children after Ltx including demographic and clinical features, immunosuppressive protocols, risk factors for fungal complications, laboratory findings, antifungal therapy and outcome. Methods: We estimated 9 cases (4.8%) of IA in 187 Ltx recipients treated in our center between 1990-2003. IA was diagnosed when clinical symptoms were associated with microbiological / histological identification of Aspergillus sp. or detection of galactomannan antigen in blood. Evaluation of antiaspergillus antibodies were used as helpful diagnostic tool. Results: 9 cases of IA(4 boys, 5 girls), aged 1.14 -21 yr (mean 9.6 yr) were assessed. 7 patients received graft from cadaveric donnor, 5 were living related recipients. The mean time from Ltx to diagnosis of IA in 8 cases was 14.5 days (5 – 30 days) in 1 boy IA was diagnosed in 5th month after transplantation. Aspergillus fumigatus was cultured in: sputum and bile in 1 case, sputum and decubitus in 1 case, in pleuritic fluid in 1 case, in sputum blood and operative wound in 1 case, in abdominal drain in 1 recipient, in BAL fluid in 1 child, in stool and blood in 1 case, in BAL fluid, sputum, perinasal sinuses, conjunctiva in 1 patient. In 2 cases histological examination confirmed IA (1 in enucleated eyeball and in 1 patient in autopsy in portal vein and hepatic artery). Galactomannan antigen was found in 2 cases and high levels of antiaspergillus antibodies in other 2 cases. Risk factors: serious bacterial coinfections and wide spectrum antibioticotherapy in all 9 cases, CMV infection and ganciclovir treatment in 6 cases, episodes of acute rejections in 5 children, relaparotomies in 7 cases (1-5 laparotomies), poor graft function in 6 recipients, retransplantation in 3 cases, hepatorenal syndrom with hemodialysis in 2 cases. All children received antifungal prophylaxis immediately after transplantation: fluconasol, nystatine, flucitosine. Patients with IA were treated with amphotericine B in 7 cases and liposomal amphotericine in 2 cases (in 1 case with itraconasol). In 3 recipients amphotericine B was administered with flucitosine, in 2 with itraconasol. Mean cumulative dose of amphotricine was 960mg (270mg-4000mg), time of treatment from 2 days to 3 months. 2 patients died because of IA (mortality rate 22 %), 1 girl died 7 years later (complications after reretransplantation). Conclusions: Most cases of IA occurs in first 30 days after Ltx. Main risk factors for IA are: poor graft function and retransplantation, relaparotomies, increased immunosuppresion because of episodes of acute rejections, long, wide spectrum antibioticotherapy because of serious bacterial infections, CMV coinfection and ganciclovir treatment. Conventional antifungal prophylaxis remains ineffective. Mortality rate in IA patients was lower than presented in other reports.