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Diagnosis of veno-occlusive disease/sinusoidal obstruction syndrome of the liver: problems of interpretation

A study was performed to investigate the air quality of a haematopoietic SCT ward, colonization of the upper airways with Aspergillus spp. and the role of galactomannan (GM) ELISA testing in serum in the diagnosis of invasive aspergillosis (IA). In 102 allo-SCT recipients, two cases of IA (one proven and one probable) were seen. Of 2071 serum samples, 12 were positive, two in a patient with proven IA and 10 in patients without IA. Of the 2059 negative samples, 22 were taken from the patient with probable IA. Of the 245 environmental samples, 20 (8.2%) were positive for filamentous fungi. Aspergillus fumigatus was seen in 14 samples. A total of 657 oral and nasal swabs were taken. Seven nasal samples and one oral sample were positive for Aspergillus species (A. fumigatus 4, A. niger 4) in four patients, one of whom had probable IA. In summary, most environmental samples were negative, colonization of the oral and nasal cavities was rare and IA was diagnosed in only 2% of patients. The GM ELISA test remained negative in one of two patients with IA and does not seem useful in a population of patients with a low incidence of IA.

A 12-week environmental study was performed to ensure that the patient rooms of an SCT ward with high-efficiency particulate air (HEPA) filtration remained uncontaminated by moulds during close-by construction work. The sampling included measuring the ventilation channel pressure, particle count measurements, air sampling, settled dust analysis and fungal cultures from the oral and nasal cavities of the patients. No changes in the air pressure occurred. Median particle counts in patient rooms were 63-420 particles/l. The mean particle count of the outside air was 173,659 particles/l. Patient room air samples were negative for aspergilli in 32 of 33 cases. All samples of the outside air were positive for moulds. Aspergillus fumigatus was isolated at the beginning of excavation works at the construction area and in two of 33 dust samples from patient rooms. All 70 nasal samples were negative. Of 35 mouth samples, one sample was positive for A. niger in a patient with a previously diagnosed aspergillus infection. During a median follow-up of 214 days, no invasive aspergillus infections were diagnosed in the 55 patients treated during the construction period. In conclusion, the HEPA filters seemed to have performed well in preventing an aspergillosis outbreak.

Invasive fungal infections (IFI) are common in allogeneic SCT recipients. We have reviewed our experience of IFI with special reference to candidaemia in 685 adult patients transplanted in 1983–2002. The donor was a matched sibling in 505 patients and an unrelated donor in 180 patients. A BM graft was used in 561 patients and a PB graft in 124 patients. Fluconazole prophylaxis was not used during the study period. Definite or probable IFI was observed in 60 patients (8.7%) with a dominance of Aspergillus infections (46 patients, incidence 6.7%). Candidaemia was found only in nine patients (1.3%). The causative agents were Candida albicans (n=8), C. krusei (n=2), and C. glabrata (n=1); in two patients, two causative agents were found. The median time to the diagnosis of candidaemia was 53 days (range 6–249 days) post transplant. Seven patients were neutropaenic at diagnosis, and four patients had experienced acute GVHD. All patients received antifungal therapy, but only one patient was cured. According to this study, candidaemia was a rare event in allogeneic SCT recipients. Thus, systematic prophylaxis against Candida infections might not be indicated. The prognosis of established infections is still poor due to comorbid conditions, notably GVHD.