title: Outcomes and factors influencing prognosis in patients with vascular pythiosis.
abstract: OBJECTIVE
  Vascular pythiosis, caused by Pythium insidiosum, is associated with a high mortality rate. We reviewed the outcomes and established the factors predicting prognosis of patients treated in our institution with surgery, antifungal therapy, or immunotherapy.
  
  
  METHODS
  We undertook a retrospective record review of patients with vascular pythiosis treated in Siriraj Hospital, Bangkok, Thailand, between January 2005 and January 2015. Patient characteristics, type of surgery, adjunctive antifungal treatment, adjunctive immunotherapy, and disease status of surgical arterial and surrounding soft tissue margins were recorded. We calculated the mortality rate and established factors predicting prognosis.
  
  
  RESULTS
  The records of 11 patients were reviewed. All patients had thalassemia. Nine patients (81.8%) had a history of contact with contaminated water. The clinical presentations were chronic ulcers (45.5%), toe gangrene (27.3%), pulsatile mass (27.3%), and acute limb ischemia (27.3%). Above-knee amputation was required in 10 patients (90.9%). The mortality rate was 36.4%. Independent variables between survivors and nonsurvivors were lack of an arterial disease-free surgical margin (P = .003), lack of a surrounding soft tissue disease-free surgical margin (P < .05), a suprainguinal lesion (P < .05) and duration of symptoms (P < .05). Adjuvant itraconazole, terbinafine, and Pythium vaccine have a role to play in patients with a disease-free arterial surgical margin but in whom infected surrounding soft tissue could not be completely excised.
  
  
  CONCLUSIONS
  Achieving adequate disease-free surgical margins-especially the arterial margin-at amputation or débridement is the most important prognostic factor in patients with vascular pythiosis. Early detection combined with a multidisciplinary approach to treatment, including surgery, antifungal agents, and immunotherapy, allows the best possible outcome to be obtained.
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand. Electronic address: nuttawut@gmail.com.
authors.forename: Nuttawut
authors.initials: N
authors.lastname: Sermsathanasawadi
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Banjerd
authors.initials: B
authors.lastname: Praditsuktavorn
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Kiattisak
authors.initials: K
authors.lastname: Hongku
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Chumpol
authors.initials: C
authors.lastname: Wongwanit
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Khamin
authors.initials: K
authors.lastname: Chinsakchai
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Chanean
authors.initials: C
authors.lastname: Ruangsetakit
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Suteekhanit
authors.initials: S
authors.lastname: Hahtapornsawan
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Pramook
authors.initials: P
authors.lastname: Mutirangura
mesh_terms: D000328:Adult; D000671:Amputation, Surgical / Q000009:adverse effects / Q000401:mortality; D000935:Antifungal Agents / Q000009:adverse effects / Q000627:therapeutic use*; D000072226:Computed Tomography Angiography; D003646:Debridement / Q000009:adverse effects / Q000401:mortality; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D007167:Immunotherapy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D008297:Male; D000072662:Margins of Excision; D008875:Middle Aged; D010274:Parasitology / Q000379:methods; D011237:Predictive Value of Tests; D058968:Pythiosis / Q000175:diagnosis / Q000401:mortality / Q000469:parasitology / Q000628:therapy*; D011775:Pythium / Q000302:isolation & purification*; D012189:Retrospective Studies; D012307:Risk Factors; D013785:Thailand; D013997:Time Factors; D016896:Treatment Outcome; D014652:Vascular Diseases / Q000175:diagnosis / Q000401:mortality / Q000469:parasitology / Q000628:therapy*; D055815:Young Adult
chemical_list: D000935:Antifungal Agents