1. LUNG TRANSPLANT Exciting Cases in Transplant Infectious Disease Presented by Silvia Vidal on behalf of her mentor Clarisse Machado

2. CLINICAL CASE  FFL, 59 yo, male, emphysema (listed since jun/2013)  Bronchopulmonary allergic aspergillosis since 2012 (sputum and positive serology (ID/CIE+)  Lung volume reduction surgery (bilateral bullectomy) - 2002  Deep vein trombosis 2002 and 2007 – alveolar hemorrhage  inferior vena cava filter and prophylaxis with enoxaparin  intermittent claudication  Arterial hypertension  Respiratory colonization: Aspergillus spp./ Stenotrophomonas maltophilia  Cardiac catheterization (dec/12): obstructive lesion (70%) left marginal artery branch

3. CLINICAL CASE  Bilateral lung transplant without CPB 17/mar/15; Ischemic time right lung 5h:45min and left lung 9hours; norepinephrine 0,2mcg/kg/min  ICU discharge PO 4  ATM: Micafungin, Piperacilin/Tazobactam, sulfametoxazole-trimethropim (donor BAL culture: E.faecalis, Staphylococcus coagulase negative and yeast; recipient cultures: negative)  Donor lymphonode: caseous necrosis with fungal form suggestive of Histoplasma spp.  Immunosuppression therapy: Tacrolimus + Azathioprine + prednisone  PO 8: pancytopenia (Hb 9,3 leuk 2900 Plt 93000 RNI 1,9)  micafungin to itraconazole, vitamin K and suspension of azathioprine  Chest X-ray: normal

5. CLINICAL CASE  PO 9 severe sepsis septic shock: blood and BAL cultures taken  Bronchoscopy (thick mucous secretion adhered to the bronchial mucosa )  ATM switched to Meropenem, Teicoplanin, levofloxacin and liposomal amphotericin  Hb 7.8 leuk 2100 (after filgastrim) Plt 21000  PO 10: Blood transfusion and Colistin  clinically stable for 48h  PO 12: acute respiratory failure  alveolar hemorrhage  ICU  death 1h after admission

6. X-RAY 9TH PO

7. X-RAY 11TH PO

8. NECROPSY Pneumonia and acute myocardial infarction LBA e HMC (27/mar/15 – post-mortem results ): Trichosporon asahii and K.pneumoniae Hodge+