Clinical Research Of Rare Complications Relative To Plasmapheresis In Patients With Severe Hepatitis: Pulmonary Aspergillosis And Anaphylactic Shock

Background:Invasive pulmonary aspergillosis(IPA) is described more frequently as acomplication of neoplastic disease in immunocompromised patients andis associated with high mortality. It mainly occurs in patients withmalignancy experienced deep and prolonged neutropenia. Hepatic failureis not a generally recognized risk factor for pulmonary aspergillosis. It israrely reported about the clinical manifestation, predisposing factor andthe ways of prevention and treatment of pulmonary aspergillosis inpatients with severe hepatitis.The impact of therapeutic plasmaexchange(TPE) on clinical manifestation of IPA in patients with severehepatitis is unclear. Anaphylactic shock occurs although sterides wereused to prevent severe anaphylactic reaction. No suitable reference can beused to predict the occurrence of anaphylactic shock in patients withtherapeutic plasma exchange. Clinical researchs have confirmed that themorbility of fungous infection increased usually after therapeutic plasmaexchange. There is no good evidence about how to use steridesappropriately in therapeutic plasma exchange.Objective:1. To assess the clinical feature, diagnosis and treatment ofpulmonary aspergillosis in patients with severe hepatitis,and explore theinfluence of therapeutic plasma exchange and sterides on clinical featureof pulmonary aspergillosis in patients with severe hepatitis.2. To explore the influence of hepatic injury on the reactive potencyof severe allergic response to anaphylactogen in patients with therapeuticplasma exchange and provid evidences for utilizing sterides individuallyin therapeutic plasma exchange.Methods:1. The 1133 hospitalized patients with severe hepatitis from Aug2001 to Aug 2006 were retrospectivly analyzed, 12 cases with invasiveaspergillosis were analysed with respect to their clinical findings,predisposing factors, complications and causes of death. 2. Retrospective investigation of acography was performed toexplore the PTA and liver function of patients with allergic shock beforetheir therapeutic plasma exchange.Results:1. Among 1133 severe hepatitis cases in 5 years, 12 patients (1.06 %)occured invasive pulmonary aspergillosis. There were 10 males and 2females. Their ages ranged from 27 to 64 years. Fever, cough with brownmucopurulent expectoration, haemoptysis, and dyspnoea were commonlyencountered symptoms. Chest pain was observed in 1 case. Chestradiography or CT scan revealed unilateral or bilateral opacities ornodular shadows. In most cases, neutrophil and leukocyte in blood wereincreased. PTA of 11 cases was lower than 30%. Contrasted to patientswithout TPE, the manifestation of IPA in patients with TPE was moreinsidious and the symptoms of which were more severe. Broad-spectrum antibiotic therapy was performed in 5 patients anddexamethasone was used to prevent severe anaphylaxis before therapeuticplasma exchange in 7 patients. Antifungal therapy was performed inonly 6 patients and in which fluconazol was used in 5 persons. Deathwas related to extensive pulmonary involvement. 10 cases died fromrespiratory function failure and 1 died from septic shock, only 1 casewhose PTA was higher than 40% cured with the treatment ofitraconazole.2. Total 1417 therapeutic plasma exchanges had been performed in780 patients. Each patients treated 1 to 11 times with therapeutic plasmaexchange.The incidence rate of anaphylactic shock was independent ofthe frequency of therapeutic plasma exchange ( x~2=0.75, P＞0.05)Allergic shock occurred in 9 patients whose PTA exceeded 30%, in which7 cases occurred in their first therapeutic plasma exchange.No patientswhose PTA was lower than 30% shew allergic shock.Conclusions:1. Severe hepatitis is one of the main risk factors for invasivepulmonary aspergillosis, especially for the patients whose PTA was lower than 30%. Therapeutic plasma exchange, corticosteroid therapy andbroad-spectrum antibiotic are predisposing factors. Contrasted to patientswithout TPE, the manifestation of IPA in patients with TPE is moreinsidious and the symptoms of which are more severe.Radiologicalinvestigations and serologic markers can be utilised for confirmation andprompt therapy. The degree of hepatic injury and effective treatment aredefinitive factors for prognosis. Itraconazole is one of the good choice forthe treatment of severe hepatitis patients with aspergillosis infection.Preventive measures, early diagnosis and treatment are obligatory tocountercheck aspergillosis infection and decrease the mortality.2. No relationship exists between the rate of allergic shock and thefrequency of therapeutic plasma exchange.The anaphylactic potency toanaphylactogen descends in patients with grave hepatic failure (especiallythose patients whose PTA was lower than 30%).The use ofdexamethasone for preventing anaphylactic shock in therapeutic plasmaexchange should be individual. Disuse or decrease the dose ofdexamethasone should be considered in patients with severe hepaticfailure to decrease the rate of invasive fungal infections. More measuresof preventing anaphylactic shock shoud be taken to those patients whosePTA is higher than 30% during their TPE treatments.