title: Fungal infection in patients with end-stage liver disease: low frequency or low index of suspicion.
abstract: BACKGROUND
  End-stage liver disease (ESLD) is associated with dysregulation of the immune system and increased susceptibility to infections. Although invasive fungal infection (IFI) is a growing public health problem, studies of IFI in ESLD are lacking. The aims of this study were to screen for IFI in ESLD and to assess risk factors and serum interleukin 17 (IL-17) as a marker of the cellular immune response.
  
  
  METHODS
  Both blood and ascitic fluid samples were collected from 46 patients with ESLD for fungal culture and PCR. Serum IL-17 levels were determined.
  
  
  RESULTS
  Seven patients had isolated IFI (four had spontaneous fungal peritonitis, two had fungemia, and one had a disseminated fungal infection) and five cases had combined fungal and bacterial infections. Spontaneous fungal peritonitis was attributed to Candida species, while fungemia was caused by Aspergillus species. Patients with IFI had higher serum IL-17 levels and increased mortality compared to patients without IFI. A history of antibiotic use (p = 0.002), higher model for end-stage liver disease (MELD) scores (p = 0.04), and hepatorenal syndrome (p = 0.006) were risk factors for IFI.
  
  
  CONCLUSIONS
  Patients with ESLD had a low frequency of IFI; however, in patients with these infections, delayed diagnosis and treatment may contribute to a high fatality rate. Thus, clinicians should have a high index of suspicion for this unusual but lethal entity, as prompt detection and appropriate treatment can improve the outcome.
authors.affiliation: Department of Tropical Medicine and Gastroenterology, 6(th) Floor, Faculty of Medicine, Assiut University, 71111, Assiut, Egypt. Electronic address: mam_elham75@yahoo.com.
authors.forename: Elham A
authors.initials: EA
authors.lastname: Hassan
authors.affiliation: Department of Tropical Medicine and Gastroenterology, 6(th) Floor, Faculty of Medicine, Assiut University, 71111, Assiut, Egypt.
authors.forename: Abeer S
authors.initials: AS
authors.lastname: Abd El-Rehim
authors.affiliation: Department of Tropical Medicine and Gastroenterology, 6(th) Floor, Faculty of Medicine, Assiut University, 71111, Assiut, Egypt.
authors.forename: Sahar M
authors.initials: SM
authors.lastname: Hassany
authors.affiliation: Department of Clinical Pathology, Faculty of Medicine, Assiut University, Assiut, Egypt.
authors.forename: Asmaa O
authors.initials: AO
authors.lastname: Ahmed
authors.affiliation: Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt.
authors.forename: Nahla M
authors.initials: NM
authors.lastname: Elsherbiny
authors.affiliation: Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt.
authors.forename: Mona H
authors.initials: MH
authors.lastname: Mohammed
mesh_terms: D000368:Aged; D001230:Aspergillus / Q000302:isolation & purification; D001663:Bilirubin / Q000097:blood; D015415:Biomarkers / Q000097:blood; D001786:Blood Glucose / Q000378:metabolism; D002175:Candida / Q000302:isolation & purification; D003404:Creatinine / Q000097:blood; D017931:DNA Primers; D004271:DNA, Fungal / Q000097:blood; D058625:End Stage Liver Disease / Q000150:complications / Q000382:microbiology* / Q000473:pathology*; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D020381:Interleukin-17 / Q000097:blood; D008297:Male; D008875:Middle Aged; D009181:Mycoses / Q000150:complications / Q000175:diagnosis* / Q000473:pathology*; D011446:Prospective Studies; D012307:Risk Factors; D012709:Serum Albumin / Q000378:metabolism; D013048:Specimen Handling
chemical_list: D015415:Biomarkers; D001786:Blood Glucose; D017931:DNA Primers; D004271:DNA, Fungal; D020381:Interleukin-17; D012709:Serum Albumin; D003404:Creatinine; D001663:Bilirubin
keywords: End-stage liver disease; Fungal infection; Fungemia; Serum IL-17; Spontaneous fungal peritonitis