title: Invasive pulmonary aspergillosis after living donor liver transplantation should be eradicated or not? A case report.
abstract: BACKGROUND
  Invasive pulmonary aspergillosis (IPA) is a rare complication with a high mortality rate after organ transplantation. Early antifungal therapy improves survival. In some cases, surgical resection is necessary for a complete remission. We have reported herein a case of sustained (but stationary) IPA cured by the modulation of immunosuppression with discontinuation of antifungal therapy.
  
  
  METHODS
  A 34-year-old man underwent liver transplantation experiencing are early bile leak and an acute rejection episode. Steroid pulse therapy was accompanied by intensified immunosuppression. After a week he developed intermittent hemoptysis, which was treated with antibiotics due to a diagnosis of pneumonia by chest X ray. Meanwhile the bile leak progressed to a huge biloma at reoperation 3 weeks after the initial operation he was converted from a choledochocholedochostomy to a hepaticojejunostomy. After 1 week, follow-up chest X ray showed the lesion had progressed to form an abscess. Subsequent chest computed tomography (CT) detected a pulmonary mass with internal necrosis and CT-guided lung biopsy revealed Aspergillus fumigatus on isolation. Antifungal therapy with voriconazole and/or amphotericin B for 3 months stopped disease progression but the lesion was sustained. We stopped antifungal therapy due to side effects and reduced the intensity of immunosuppression. Follow-up chest CT 5 months later showed improvement with a persistent cavitary lesion containing a fungal ball. However, after 9 months, there was no focal lesion in either lung. This unusual case of IPA was cured by reducing immunosuppression without antifungal therapy.
  
  
  CONCLUSIONS
  IPA should be eradicated with prompt antifugal therapy, but stationary IPA can be observed cautiously while reducing immunosuppression.
authors.affiliation: Department of Surgery, Korea University College of Medicine, Seoul, Korea. mass64@hanmail.net
authors.forename: J W
authors.initials: JW
authors.lastname: Park
authors.forename: J H
authors.initials: JH
authors.lastname: Kim
authors.forename: W B
authors.initials: WB
authors.lastname: Kim
authors.forename: H J
authors.initials: HJ
authors.lastname: Han
authors.forename: S B
authors.initials: SB
authors.lastname: Choi
authors.forename: J E
authors.initials: JE
authors.lastname: Yeon
authors.forename: K S
authors.initials: KS
authors.lastname: Byun
authors.forename: S Y
authors.initials: SY
authors.lastname: Choi
mesh_terms: D000328:Adult; D000935:Antifungal Agents / Q000009:adverse effects / Q000627:therapeutic use*; D004359:Drug Therapy, Combination; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage*; D055744:Invasive Pulmonary Aspergillosis / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000382:microbiology; D016031:Liver Transplantation / Q000009:adverse effects*; D019520:Living Donors; D008297:Male; D009173:Mycophenolic Acid / Q000008:administration & dosage / Q000031:analogs & derivatives; D013256:Steroids / Q000008:administration & dosage; D016559:Tacrolimus / Q000008:administration & dosage; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D000935:Antifungal Agents; D007166:Immunosuppressive Agents; D013256:Steroids; D009173:Mycophenolic Acid; D016559:Tacrolimus