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DOI: 10.1055/a-2261-7977
Cholangioscopy findings of biliary candidiasis post-liver transplantation
Solid organ transplant patients are often subject to immunosuppressive agents, which predispose them to opportunistic infections. Of those infectious agents, fungal infections such as Candida are associated with the highest mortality rate [1].
A 51-year-old man with a history of cirrhosis after orthotopic liver transplantation, with postoperative course complicated by bile leak that was treated with placement of a covered metal stent, was found on magnetic resonance imaging to have filling defects in the intrahepatic ducts suggestive of either debris or fungal balls ([Fig. 1]). As the patient had persistent fungemia with Candida glabrata despite treatment, he underwent endoscopic retrograde cholangiopancreatography (ERCP) for further evaluation.
Cholangioscopy ([Video 1]) during ERCP revealed diffuse irregularities at the hepatic duct confluence, consisting of large amounts of brown fibrous tissue ([Fig. 2]). Additionally, black streaks were scattered throughout the left hepatic ducts ([Fig. 3]). Cholangioscopy-guided biopsies and brush cytology were obtained, as well as cultures from the biopsies and aspirated biliary fluid. Then, 500 mL of amphotericin B (50 mg/500 mL) were directly instilled into the intrahepatic ducts via the cholangioscope over 30 minutes.
Quality:
Brush cytology and intraductal biopsies revealed fungal organisms morphologically consistent with Candida ([Fig. 4]), in addition to ulcerated mucosa with fungal cultures growing Candida glabrata. As a salvage treatment, we repeated ERCP 1 week later with placement of a nasobiliary drain into the right hepatic duct. The patient received intrabiliary irrigation of amphotericin 12.5 mg three times daily, in addition to parenteral liposomal amphotericin and oral flucytosine, which resulted in resolution of the fungemia.
Repeat ERCP after 2 weeks of this regimen showed significantly improved fibrous-like material in the right hepatic duct ([Fig. 5]), with mild improvement in the left hepatic duct. Owing to persistent fungemia and bacteremia, however, the patient required repeat liver transplantation 3 months later.
Endoscopy_UCTN_Code_TTT_1AR_2AK
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Publication History
Article published online:
22 February 2024
© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).
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Reference
- 1 Shoham S, Marr KA. Invasive fungal infections in solid organ transplant recipients. Future Microbiol 2012; 7: 639-655 DOI: 10.2217/fmb.12.28. (PMID: 22568718)