Clinical case
Aorto-bifermoral graft infection due to Candida parapsilosis. An unusual pathogen
Infección de injerto aortobifemoral por Candida parapsilosis. Un germen inhabitual
Kerbi Alejandro Guevara-Noriegaa,
, Alina Velescua, Diana Teresa Zaffalon-Espinalb, Eduardo Mateos-Torresa, Luis Roig-Santamaríaa, Albert Clará-Velascoa
Corresponding author
kerbiguevara@hotmail.com
Corresponding author at: Calle Bilbao 110, Piso 8 Puerta 6, 08018 Barcelona, Spain. Tel.: +34 628888896.
Corresponding author at: Calle Bilbao 110, Piso 8 Puerta 6, 08018 Barcelona, Spain. Tel.: +34 628888896.
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An unusual pathogen" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "234" "paginaFinal" => "239" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Kerbi Alejandro Guevara-Noriega, Alina Velescu, Diana Teresa Zaffalon-Espinal, Eduardo Mateos-Torres, Luis Roig-Santamaría, Albert Clará-Velasco" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Kerbi Alejandro" "apellidos" => "Guevara-Noriega" "email" => array:1 [ 0 => "kerbiguevara@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Alina" "apellidos" => "Velescu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Diana Teresa" "apellidos" => "Zaffalon-Espinal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Eduardo" "apellidos" => "Mateos-Torres" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Luis" "apellidos" => "Roig-Santamaría" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Albert" "apellidos" => "Clará-Velasco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Angiología y Cirugía Vascular, Parc de Salut Mar Barcelona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Aparato Digestivo, Parc de Salut Mar Barcelona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Calle Bilbao 110, Piso 8 Puerta 6, 08018 Barcelona, Spain. Tel.: +34 628888896." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Infección de injerto aortobifemoral por <span class="elsevierStyleItalic">Candida parapsilosis</span>. Un germen inhabitual" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 838 "Ancho" => 975 "Tamanyo" => 72169 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Upper digestive tract endoscopy. P: exposure of Dacron prosthesis through the duodenal lumen.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Aorto-enteric fistula is a rare and potentially lethal entity the presentation of which may be due to communication between the aorta, usually aneurysmal, and the enteric tract (primary fistula) or after reconstructive procedures with vascular prosthesis, aorto-renal bypass or endarterectomy (secondary fistula). The latter procedure may present in two ways: by anaestomotic communication between the aortic and intestinal lumen, known as the true enteric-prosthetic fistula and less commonly, due to aorto-enteric erosion, enteroparaprosthetic sinus infection or enteric-prosthetic fistula, where injury is a consequence of direct contact with the vascular graft.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The incidence rate of secondary aorto-enteric fistulae is low, between 0.4% and 1.6%,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> which is not insignificant considering the frequency of grafts implanted. The most common aetiological germ is <span class="elsevierStyleItalic">Staphylococcus spp.</span> which accounts for 40% of cases, gram-negative bacilli, which together represent a similar percentage and polymicrobian infections which account for 10–15% of cases.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> Fungal infections are rare, and there is no known evidence for <span class="elsevierStyleItalic">Candida parapsilosis</span>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The candida genre is considered as an emerging fungal infection for which many pathogenic mechanisms have been described, such as: the production of prostaglandins, and particularly D2 and E2, which modulate the response of helper lymphocytes, derive their response to Th2 and confer the candida with a resistance mechanism. The creation of biofilms has also been described and high inflammatory responses relating to interleukin 22 and tumour necrosis factor-alpha.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Hospital-acquired infection has been cited as the main mechanism of transmission, with fungemia as the major morbidity factor since in several regions of the world <span class="elsevierStyleItalic">C. parapsilosis</span> is considered the most commonly isolated germ in these cases, although in the United States and northern European countries <span class="elsevierStyleItalic">Candida albicans</span> and <span class="elsevierStyleItalic">Candida glabarata</span> are the most common germs. Other morbidities have been reported including: endocarditis on the prosthetic valve, arthritis and onicomicosis.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">8,9</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Objective</span><p id="par0025" class="elsevierStylePara elsevierViewall">To present a case of enteric-prosthetic fistula, from which the only isolated germ was <span class="elsevierStyleItalic">C. parapsilosis</span>, an unusual pathogen.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Clinical case</span><p id="par0030" class="elsevierStylePara elsevierViewall">A male patient aged 65, a smoker of 68 packs per year and with no other history of note, was referred to our hospital due to critical ischaemia of lower extremities with ankle-arm rates of 0.31 right and 0.19 left. The following was deduced from the digital arteriogram: double bilateral renal artery, with aorta porosity, common right iliac and right hypogastric artery with occlusion of the right external iliac artery and the whole left iliac axis; occlusion of both common femoral arteries, superficial femoral arteries and profound femoral arteries where they begin, with porosity of distal branches of the profound femoral artery through the collateral arteries. The popliteal arteries and the distal trunks were bilaterally porous.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Aortobifemoral bypass was performed with a dacron (16×8<span class="elsevierStyleHsp" style=""></span>mm, Vaskutek Ltd. Scotland, United Kingdom) prosthesis with proximal side-to-end anastomosis in the aorta and end-to-side in both profound femoral arteries. Antibiotic prophylaxis protocols were correctly followed and were appropriate for this type of surgery. They therefore included: 2<span class="elsevierStyleHsp" style=""></span>g amoxicillin clavulanic acid+210<span class="elsevierStyleHsp" style=""></span>mg single dose gentamycin prior to procedure. The only postoperative event of note was paralytic ileus which was resolved with medical treatment. Postoperative angle-arm rates were 0.54 on both sides.</p><p id="par0040" class="elsevierStylePara elsevierViewall">After 6 months the patient was operated on again for acute ischaemia of the left lower limb, occlusion of the left branch of the aorto-bifemeral graft. Thrombectomy and prolongation of left popleteal artery was performed. Antibiotic prophylaxis was again adhered to.</p><p id="par0045" class="elsevierStylePara elsevierViewall">8 months after reintervention, an angiograph was performed due to the suspicion of stenosis of the right branch, detected in ultrasound controls, the severity of which was not confirmed and as a result a wait-and-see approach was adopted.</p><p id="par0050" class="elsevierStylePara elsevierViewall">After 22 months the patient was admitted to hospital again for the study of a toxic syndrome with clinical data of 5–6 months evolution, and which consisted of: a 10<span class="elsevierStyleHsp" style=""></span>kg weight loss, anorexia, asthenia, sensation of postprandial fullness, odynophagia, dysphagia, nausea, vomiting, abdominal pain with change in intestinal habits and evacuations. No upper or lower digestive haemorrhaging or fever or feeling of dysthermia presented.</p><p id="par0055" class="elsevierStylePara elsevierViewall">A physical examination revealed nothing abnormal, save for the presence of a non-throbbing tumour in the left inguinal region. Femoral pulses were present, with no clinical signs of distal ischaemia or trophic lesions.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The CAT angiograph showed: hypodense halo in the region next to the bypass, with the presence of air in intimate contact with the third duodenal segment and a dotted line in the proximity of the intestinal lumen. We also observed hypdense protrusion towards the prosthesis lumen, as a continuation of the before-mentioned hypodense halo (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). From a radiological viewpoint, findings were suggestive of graft infection.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">An upper endoscopy showed contact with the Dacron prosthesis through the intestinal lumen at the first duodenal segment level (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The gamma graph showed a circumscriptive infectious process at the periprosthetic region with extension from the beginning of the upper mesenteric artery to the iliac bifurcation, with no evidence of infection in other sites (<a class="elsevierStyleCrossRef" href="#fig0025">fig. 5</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Laboratory tests highlighted: leukocytes 14,600/mm<span class="elsevierStyleSup">3</span>, with 80% netrophyl; C reactive protein (6.2<span class="elsevierStyleHsp" style=""></span>mg/dl); prothrombin of 62% (INR de 1.41). The other tests performed to locate an alternative focus of infection resulted negative.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Two-stage surgery was scheduled. First-stage surgery was an immediate axillofemoral bypass with expanded polytetrafluoroethylene and disconnection of both femoral branches from the previous bypass. One week later second-stage surgery was performed, which was put forward on observation of lower gastrointestinal bleeding with a laboratory test lowering of 2<span class="elsevierStyleHsp" style=""></span>g/dl of red blood cells. During surgery we observed that the Treitz angle was intimately attached to a peri-aortic flogotic mass. Once sectioned, we were able to see the absence of the posterior duodenal wall at third segment level, with the prosthesis externalising towards it. The aorto-bifemoral prosthesis was removed and suturing of the infrarenal aortic stump was performed with double raffia 0 prolene sutures. Duodenal excision was performed with transmesocolic side-to-side anastomosis at the anterior side of the second duodenal segment.</p><p id="par0085" class="elsevierStylePara elsevierViewall">3 culture samples were taken during surgery which corresponded to the duodenal segment in contact with the prosthesis, the prosthetic segment and a smear of peri-prosthetic fluid, all of which tested positive for <span class="elsevierStyleItalic">C. parapsilosis</span> (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>).</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The post-operative period was uneventful except for paralytic ileus, which was resolved with medical treatment. Postoperative treatment was initially with intravenous fluconazol which was continued orally on hospital discharge. After 2 years the patient is within normal limits physically, denies any symptoms and has not had any posterior examinations due to his refusal to go for checkups.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">Enteric-paraprosthetic fistulae have been reported on occasions as prosthetic erosion or aorto-enteric erosion. The most common location, as occurred in our case, is in the duodenum. In the case referred to the literature, the indication from Lerich's syndrome contrasted with that reported in other publications, which showed almost insignificant incidence when the technique is performed on occlusive arterial disease.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4,10</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Clinical signs described for entero-paraprosthetic fistulae may vary from gastrointestinal haemorrhaging to non specific clinical symptoms characterised by weight loss, fever which may range from occasional fever to septic shock, abdominal pain or non specific symptoms.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Our patient was admitted to hospital on suspicion of a toxic syndrome and the finding was incidental during a radiological procedure. However, it should be noted that second-stage surgery was put forward on observation of a low gastrointestinal tract haemorrhage.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> The CT angiograph showed standard images such as periprosthetic gas, and direct contact of the intestine with inflammatory tissue and the prosthesis.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The following have been described among the risk factors for <span class="elsevierStyleItalic">C. parapsilosis</span>: the use of antibiotics such as vancomycin and doripenem and possible connection of a history of alcohol dependence. There was no history of usage of these antimicrobial agents in the case we present nor recent hospital admittances, nor any significant alcohol dependence or consumption.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Many approaches to the treatment of this entity have been described, from a conservative non surgical approach to the local repair with removal of the graft and in situ replacement, or as in our case, associated with extra anatomical revascularisation. Outcome is varied, depending on the literature consulted.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2,12</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">With regard to antibiotic treatment, the susceptibility of the germ enables its treatment with: amphotericin B, fluconazol, itraconazol, voriconazol and caspofungin. However, resistance to fluconazol has mainly been described related to the post exposure mutation of genes to ERG11, CDR1 and less commonly MDR1 which code drug efflux pumps. Our first line antifungal treatment was fluconazol, with no evidence of germ persistence after treatment.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">13,14</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Notwithstanding, our most relevant finding was the presence of <span class="elsevierStyleItalic">C. parapsilosis</span> in all cultures taken during surgery, with negative blood cultures and no other known foci of infection. Mechanisms of infection have classically been described as direct contamination of the prosthesis when implanted, in which case presentation period is usually the year after implantation, but not in our case. Another possibility is deferred infection via haematogene, but our patients did not present other possible foci of infection. All of the above calls into question the microbiological findings in these cases.</p><p id="par0130" class="elsevierStylePara elsevierViewall">In addition, standard culture techniques and typification using viability in CHROMagar and Sabouraud mediums described typification techniques through genomic analysis. In our case we used Sabouraud agar, since no genomic kits were available in our centre. Even so, in our case, the <span class="elsevierStyleItalic">C. parapsilosis</span> findings were only considered to adjust the antifungal therapy. It is unknown whether etiopathogenic mechanisms of the germ, such as haemolytic activity, phospholipase, esterase and phytase played a definitive role in the evolution of our patient, since they were not analysed.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">It is known that the low virulence of <span class="elsevierStyleItalic">C. parapsilosis</span>, limited with respect to other candida species is mainly related to endocarditis in cases of parenteral drug use, pre-existing valvular diseases, previous heart surgeries, and is more lethal in diabetic patients.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">15,16</span></a> None of these conditions was present in our patient. Our study included the performing of a transthoracic and transoesophageal echocardiogram which ruled out the presence of endocarditis. Other diseases related to <span class="elsevierStyleItalic">C. parapsilosis</span> are endophthalmitis, arthritis and peritonitis, usually related to previous invasive procedures.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">Entero-prosthetic fistulae is particularly complex to diagnose and associated with raised morbidity and mortality Graft infection by <span class="elsevierStyleItalic">C. parapsilosis</span> may be anecdotal but its consequences may also be severe. Microbiological tests can be useful to adjust antimicrobial therapy in the post-operative period, but their usefulness for determining aetiology is doubtful, as it may be just an incidental finding.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Diagnosis of entero-prosthetic fistulae should be considered in patients with a history of aortic graft with clinical signs of febrile syndrome, with or without associated gastrointestinal haemorrhaging. Upper digestive endoscopy used as first line initiative in the case of upper gastrointestinal tract haemorrhage may show direct visualisation of part of the prosthetic wall in the intestinal lumen, although this procedure may concur risks.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethical disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Protection of human and animal subjects</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Confidentiality of data</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Right to privacy and informed consent</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflict of interests</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres853195" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Clinical case" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Discussion" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec847708" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres853194" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Caso clínico" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Discusión" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec847709" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Objective" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Clinical case" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-05-19" "fechaAceptado" => "2016-01-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec847708" "palabras" => array:4 [ 0 => "Graft infection" 1 => "<span class="elsevierStyleItalic">Candida parapsilosis</span>" 2 => "Gastroscopy" 3 => "Enteric-prosthetic fistulae" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec847709" "palabras" => array:4 [ 0 => "Infección protésica" 1 => "<span class="elsevierStyleItalic">Candida parapsilosis</span>" 2 => "Gastropatía" 3 => "Fístula enteroprotésica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Aorto-enteric fistula is a rare and potentially lethal entity. Its presentation may be as an enteric-paraprosthetic fistula, due to injury in the gut caused by direct contact with the vascular prosthesis.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report a case of enteric-paraprosthetic fistulae with the unusual finding of <span class="elsevierStyleItalic">Candida parapsilosis</span> as the only isolated pathogen.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Clinical case</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A 65-year-old male, smoker, with aortobifemoral revascularisation with dacron due to aortoiliac occlusive disease, and re-intervention for thrombosis of left arm at 6 months. Hospitalisation at 22 months was required due to a toxic syndrome, which was diagnosed as enteric-paraprosthetic fistulae after complementary studies. The graft was removed and an extra-anatomic revascularisation was performed. Microbiology specimens taken from the duodenal segment in contact with the prosthesis showed the prosthetic segment and peri-prosthetic fluid were positive to <span class="elsevierStyleItalic">C. parapsilosis</span>.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The finding of <span class="elsevierStyleItalic">C. parapsilosis</span> in all cultures taken during surgery, along with negative blood cultures and no other known sources of infection, is of interest. It is an unusual pathogen with low virulence and limited as regards other Candida species. Our patient had no clinical data common to cases of infection with <span class="elsevierStyleItalic">C. parapsilosis</span>, and the mechanism of graft infection is unknown.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Graft infection by <span class="elsevierStyleItalic">C. parapsilosis</span> may be anecdotal. However, its consequences can also be severe. Microbiological tests can be useful to adjust antimicrobial therapy in the post-operative period, but their usefulness for determining the aetiology is doubtful, as it may be just an incidental finding.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Clinical case" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Discussion" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La fístula aortoentérica es una entidad rara y potencialmente letal; entre sus presentaciones se encuentra la fístula enteroparaprotésica, producto de una lesión en el intestino como consecuencia del contacto directo con la prótesis vascular.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Este reporte trata de un caso de fístula enteroparaprotésica, donde el único germen aislado fue <span class="elsevierStyleItalic">Candida parapsilosis</span>, un germen inhabitual.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Caso clínico</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Hombre de 65 años de edad, fumador, con <span class="elsevierStyleItalic">bypass</span> aortobifemoral de dacron por enfermedad oclusiva aortoilíaca, que fue reintervenido por trombosis de la rama izquierda a los 6 meses. Fue hospitalizado a los 22 meses por síndrome tóxico que tras exploraciones complementarias fue diagnosticado como fístula enteroparaprotésica. Se le retiró la prótesis y posteriormente se le realizó revascularización extraanatómica. Las muestras microbiológicas extraídas del segmento duodenal, en contacto con la prótesis del segmento protésico y del frotis del líquido periprotésico, fueron positivas para <span class="elsevierStyleItalic">C. parapsilosis</span>.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discusión</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Es relevante la presencia de <span class="elsevierStyleItalic">C. parapsilosis</span> en los cultivos tomados durante la cirugía, con hemocultivos negativos y sin otros focos infecciosos conocidos. Este es un germen inhabitual, con baja virulencia, limitada con respecto a otras especies de Cándida. Nuestro paciente no presentó datos clínicos habituales en casos de infección por <span class="elsevierStyleItalic">C. parapsilosis</span> y se desconoce el mecanismo de infección de la prótesis.</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusión</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La fístula enteroparaprotésica por <span class="elsevierStyleItalic">C. parapsilosis</span> puede resultar anecdótica; sin embargo, sus consecuencias pueden ser igual de graves. El estudio microbiológico resulta útil para ajustar una terapia antibiótica posterior a la cirugía. Queda en entredicho su utilidad para la determinación etiológica y puede incluso tratarse de un hallazgo incidental.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Caso clínico" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Discusión" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Guevara-Noriega KA, Velescu A, Zaffalon-Espinal DT, Mateos-Torres E, Roig-Santamaría L, Clará-Velasco A. Infección de injerto aortobifemoral por <span class="elsevierStyleItalic">Candida parapsilosis</span>. Un germen inhabitual. Cir Cir. 2017;85:234–239.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 861 "Ancho" => 975 "Tamanyo" => 92552 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Computed axial tomography, axial slice. Showed hypodense ring in the segment proximal to the bypass, with the presence of air in intimate contact with the third duodenal segment and visualisation of a doubtful contiguous line with intestinal lumen.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 730 "Ancho" => 975 "Tamanyo" => 98293 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Computed axial tomography, coronal slice. Hypodense protrusions are observed towards the prosthesis lumen, in contiguity with the hypodense ring.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 830 "Ancho" => 975 "Tamanyo" => 79197 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Upper digestive tract endoscopy. P: exposure of Dacron prosthesis through the duodenal lumen.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 838 "Ancho" => 975 "Tamanyo" => 72169 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Upper digestive tract endoscopy. P: exposure of Dacron prosthesis through the duodenal lumen.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 891 "Ancho" => 975 "Tamanyo" => 35503 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Gammagram marked with leukocytes suggestive of graft infection.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1423 "Ancho" => 850 "Tamanyo" => 113909 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Surgical field, with prosthetic exposure. Letters A, B and C mark the sites where 3 samples were taken during surgery for cultures. These correspond to: (A) the duodenal segment in contact with the prosthesis, (B) the prosthetic segment and (C) the periprosthetic fluid smear.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraprosthetic extravasation of enteric contrast: a rare and direct sign of secondary aortoenteric fístula" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.M. Peirce" 1 => "R.H. Jenkins" 2 => "P. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 3 | 0 | 3 |
| 2024 September | 38 | 2 | 40 |
| 2024 August | 15 | 2 | 17 |
| 2024 July | 13 | 1 | 14 |
| 2024 June | 5 | 3 | 8 |
| 2024 May | 10 | 3 | 13 |
| 2024 April | 8 | 7 | 15 |
| 2024 March | 25 | 6 | 31 |
| 2024 February | 10 | 6 | 16 |
| 2024 January | 13 | 5 | 18 |
| 2023 December | 18 | 4 | 22 |
| 2023 November | 15 | 2 | 17 |
| 2023 October | 16 | 5 | 21 |
| 2023 September | 11 | 7 | 18 |
| 2023 August | 11 | 4 | 15 |
| 2023 July | 7 | 6 | 13 |
| 2023 June | 22 | 6 | 28 |
| 2023 May | 37 | 2 | 39 |
| 2023 April | 29 | 0 | 29 |
| 2023 March | 19 | 2 | 21 |
| 2023 February | 17 | 7 | 24 |
| 2023 January | 12 | 2 | 14 |
| 2022 December | 13 | 14 | 27 |
| 2022 November | 8 | 9 | 17 |
| 2022 October | 15 | 7 | 22 |
| 2022 September | 10 | 5 | 15 |
| 2022 August | 11 | 9 | 20 |
| 2022 July | 12 | 6 | 18 |
| 2022 June | 12 | 7 | 19 |
| 2022 May | 9 | 8 | 17 |
| 2022 April | 5 | 4 | 9 |
| 2022 March | 5 | 10 | 15 |
| 2022 February | 8 | 7 | 15 |
| 2022 January | 19 | 6 | 25 |
| 2021 December | 9 | 13 | 22 |
| 2021 November | 12 | 6 | 18 |
| 2021 October | 16 | 9 | 25 |
| 2021 September | 11 | 10 | 21 |
| 2021 August | 10 | 3 | 13 |
| 2021 July | 9 | 18 | 27 |
| 2021 June | 10 | 11 | 21 |
| 2021 May | 12 | 8 | 20 |
| 2021 April | 10 | 11 | 21 |
| 2021 March | 13 | 12 | 25 |
| 2021 February | 9 | 12 | 21 |
| 2021 January | 5 | 14 | 19 |
| 2020 December | 11 | 11 | 22 |
| 2020 November | 12 | 8 | 20 |
| 2020 October | 15 | 10 | 25 |
| 2020 September | 8 | 11 | 19 |
| 2020 August | 16 | 13 | 29 |
| 2020 July | 12 | 13 | 25 |
| 2020 June | 7 | 7 | 14 |
| 2020 May | 11 | 8 | 19 |
| 2020 April | 4 | 6 | 10 |
| 2020 March | 11 | 3 | 14 |
| 2020 February | 9 | 8 | 17 |
| 2020 January | 9 | 6 | 15 |
| 2019 December | 11 | 10 | 21 |
| 2019 November | 7 | 7 | 14 |
| 2019 October | 7 | 4 | 11 |
| 2019 September | 7 | 4 | 11 |
| 2019 August | 7 | 5 | 12 |
| 2019 July | 10 | 3 | 13 |
| 2019 June | 26 | 14 | 40 |
| 2019 May | 54 | 45 | 99 |
| 2019 April | 29 | 20 | 49 |
| 2019 March | 13 | 0 | 13 |
| 2019 February | 9 | 9 | 18 |
| 2019 January | 12 | 1 | 13 |
| 2018 December | 6 | 9 | 15 |
| 2018 November | 7 | 2 | 9 |
| 2018 October | 14 | 2 | 16 |
| 2018 September | 35 | 8 | 43 |
| 2018 August | 7 | 7 | 14 |
| 2018 July | 8 | 1 | 9 |
| 2018 June | 9 | 3 | 12 |
| 2018 May | 10 | 4 | 14 |
| 2018 April | 7 | 2 | 9 |
| 2018 March | 10 | 1 | 11 |
| 2018 February | 13 | 2 | 15 |
| 2018 January | 11 | 0 | 11 |
| 2017 December | 35 | 2 | 37 |
| 2017 November | 15 | 0 | 15 |
| 2017 October | 9 | 0 | 9 |
| 2017 September | 26 | 11 | 37 |
| 2017 August | 11 | 2 | 13 |
| 2017 July | 10 | 3 | 13 |
| 2017 June | 12 | 8 | 20 |
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