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Page 14 / Case 10.03

PROPHYLAXIS

Fluconazole proved to be effective in prophylaxis against fungal infection in neutropenic pediatric patients with daily doses of 1-4 mg/kg. Cap et al chemotherapy 93
– Initial study of Aerosol Amphotercin B of 10 mg twice daily was promising in prevention of IPA in neutropenic patients. Behre et al Ann Hematol 95
Itraconzole reduced the frequency of systemic fungal infections and the use of empirical Amphotercin B. (a double blind, placebo control, and randomized trial) Nucci et al clinic INF dis 00
Itraconazole is a broad-spectrum sys. Anti-fungal with prophylactic activity in neutropenic patients. (a double-blind, randomized, multi center comparing Itra : Amph.B for prophylaxis of systemic fungal infection) J.L.Harousseau et al,Antimicrobial agents and chemotherapy, 2000

SURGICAL INTERVENTION
Advantage:
– May prevent local extension or haematogenous dissemination of the infection
– May allow early continuation of the chemotherapy.

Indication:
– Well defined lesion or aspergilloma that not responding to anti-fungal treatment.

Timing:
– ~50% done as an emergency based on chest CT observation with a lesion in contact with large pulmonary arteries. Caillot et al J of clinical oncology 97

THORACOSCOPY

– Full thoracoscopic resection of fungal infection is feasible, even for lobectomies; it allows a simpler postoperative course and minimizes sequelae. Dominique Gossot et al,Ann thorac surg, 2002
– Surgical resection of IPA cleared aspergillus infection in 69% of pateints. Neutropenia, extra-pulmonary ext., allogenic BMT could predict worse prognosis. Salerno et al Ann thorac surg 98
– Surgical resection of aspergilloma is effective in preventing recurrence of hemoptysis, with relatively law mortality5.7%. Regnard et al Ann thorac surg 00
– Surgical intervention to treat IPA appeared to have a beneficial impact on the disease control and the survival. Habich et al hematology J 2001
– Surgical resection is a therapeutic option for IPA in neutropenic patients with hematological diseases and associated with low risk morbidity and mortality Reichnberger et al AM J resp crit care med 98

BRONCHIAL ARTERY EMBOLIZATION
– Now considered the most effective non surgical treatment in the massive hemoptysis, with success might approach 98%, but before embolization selective bronchial artiography should be performed to assess size and distribution of bronchial arteries. If the spinal cord arteries arise from the bronchial arteries the embolization is contra indicated. Hemoptysis in children by Paul Pianosi and H al-sadoon, ped in review 96, Eddy jean-Baptiste crit care med 2000, role of bronch in massive hemoptysis, by RaedA Dweik et al clinics in chest med, 99.


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