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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Constrictive pericarditis may follow any cardiac surgical procedure&#44; with an incidence varying between 0&#46;1&#37; and 0&#46;3&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However&#44; this complication has been rarely described after orthotopic heart transplantation &#40;OHT&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> Since diagnosis requires a high index of suspicion in those recipients presenting with symptoms of right heart failure and preserved left systolic function&#44; diagnosis may be delayed for several months&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleItalic">Candida</span> pericarditis constitutes a rare condition associated to immunosuppression&#44; broad-spectrum antibiotherapy&#44; or previous pericardiotomy&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 54-year-old male&#44; diagnosed 4 years before of non-ischemic dilated cardiomyopathy&#44; was admitted to our institution in September 2008 because of rapidly progressive congestive heart failure&#46; Despite intensive treatment persistent hemodynamic instability prompted us to use an intra-aortic balloon pump as a bridge to urgent OHT&#46; Perioperative cultures routinely obtained from the donor and preservation fluid were negative&#46; Both the transplant procedure and the early postoperative period were uneventful&#46; Basiliximab was administered as induction therapy&#44; whereas the maintenance immunosuppression included cyclosporine A&#44; mycophenolate mofetil&#44; and prednisone&#46; An echocardiography &#40;EC&#41; performed two weeks later revealed a moderate-to-severe pericardial effusion with some fibrin strands&#44; with no signs of hemodynamic compromise&#46; In view of the absence of symptoms of cardiac tamponade or heart failure the patient was discharged home&#46; Over the next month he developed slight ankle edema&#46; EC disclosed the persistence of severe pericardial effusion with multiple&#44; highly mobile&#44; filamentous strands arising from a thickened pericardium&#46; He remained afebrile throughout the entire episode&#46; Physical examination showed tachycardia&#44; jugular vein distention&#44; and paradoxical pulse&#46; Laboratory data included a white cell count of 9&#46;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span><span class="elsevierStyleHsp" style=""></span>L<span class="elsevierStyleSup">&#8722;1</span> &#40;81&#46;9&#37; neutrophils&#41;&#44; platelets 228<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span> L<span class="elsevierStyleSup">&#8722;1</span>&#44; serum creatinine 1&#46;56<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>dL<span class="elsevierStyleSup">&#8722;1</span>&#44; and through levels of cyclosporine A and mycophenolate mofetil within therapeutic range&#46; Echocardiographic-guided pericardiocentesis yielded 1500<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span> of sero-hematic fluid&#46; Analysis of the effusion showed a leukocyte count of 8<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span><span class="elsevierStyleHsp" style=""></span>L<span class="elsevierStyleSup">&#8722;1</span> &#40;80&#37; neutrophils&#41;&#44; glucose concentration of 20&#46;0<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>dL<span class="elsevierStyleSup">&#8722;1</span>&#44; and lactic dehydrogenase level of 6690<span class="elsevierStyleHsp" style=""></span>IU<span class="elsevierStyleHsp" style=""></span>L<span class="elsevierStyleSup">&#8722;1</span>&#46; On the fifth day pericardial fluid cultures yielded <span class="elsevierStyleItalic">Candida albicans</span> &#40;<span class="elsevierStyleItalic">C&#46; albicans</span>&#41;&#46; The patient underwent a pericardial window via left anterior minithoracotomy with evacuation of 450<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>&#46; Significant pericardial thickening was confirmed&#44; and <span class="elsevierStyleItalic">C&#46; albicans</span> was isolated from the pericardial tissue culture&#46; Blood and urine cultures were negative&#59; there were no fundoscopic signs of chorioretinitis&#46; Liposomal amphotericin B &#40;L-AmB&#41; &#40;3<span class="elsevierStyleHsp" style=""></span>mg&#47;kg daily&#41; was prescribed for 2 weeks&#46; A new EC revealed progressive&#44; irregular thickening of both pericardial layers and respiratory variations of mitral and tricuspid inflows velocities&#46; A median sternotomy and a bilateral antephrenic pericardiectomy with epicardial decortication were completed&#46; Pericardium was markedly thickened with organized pleuropericardial adhesions&#46; <span class="elsevierStyleItalic">C&#46; albicans</span> was cultured from surgical specimens&#46; L-AmB was switched to oral fluconazole &#40;200<span class="elsevierStyleHsp" style=""></span>mg twice a day&#41; after 6 weeks&#46; EC showed normal graft function and filling pressures&#44; and the patient was discharged&#46; Fluconazole was continued for 12 months on an ambulatory basis&#46; Three years later the patient remains asymptomatic&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Primary pericarditis caused by <span class="elsevierStyleItalic">Candida</span> spp&#46; is a rare condition&#46; Rabinovici et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> identified a number of predisposing factors&#58; malignancy &#40;27&#37;&#41;&#44; previous antibiotic &#40;62&#37;&#41; or corticosteroid therapy &#40;15&#37;&#41;&#44; diabetes mellitus &#40;15&#37;&#41;&#44; and pericardiotomy &#40;38&#37;&#41;&#46; Cardiac tamponade was present in 8 of 12 patients for whom data were available&#46; Pericardiocentesis alone constituted the definitive treatment in only one of 10 patients&#44; and surgical drainage of the pericardial sac was required in the remaining cases&#44; with an overall survival of 56&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The diagnosis relies on the culture of pericardial fluid or pericardium specimens&#44; accompanied or not by the histological documentation of tissue invasion by the fungus&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Molecular methods based on polymerase chain reaction may also provide a reliable and earlier diagnostic approach&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In our knowledge&#44; we herein describe the third case of <span class="elsevierStyleItalic">Candida</span> pericarditis in an OHT recipient &#40;PubMed search using terms &#8220;heart transplant&#8221;&#44; &#8220;Candida&#8221; and &#8220;pericarditis&#8221;&#41;&#46; Canver et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> reported a 52-year-old patient who presented 14 months after the procedure with symptoms of heart failure&#59; postoperative period had been unremarkable and immunosuppression regimen was not specified&#59; due to rapid hemodynamic deterioration the patient underwent surgical drainage and total pericardiectomy&#44; associated with an 8-week course of L-AmB followed by oral fluconazole indefinitely&#46; Puius and Scully<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> described a 37-year-old female who received rabbit antithymocyte globulin and daclizumab as induction therapy&#59; early postoperative period was complicated with acute renal failure requiring continuous veno-venous hemofiltration&#59; clinical condition did not resolve until retained epicardial pacing wires were removed and a pericardial window was done&#46; In contrast to these cases&#44; our patient only had mild symptoms of heart failure&#44; and no evidence of systemic infection&#46; <span class="elsevierStyleItalic">Candida</span> constrictive pericarditis appeared prematurely in the post-transplant period&#44; without any significant postoperative events or additional risk factors for invasive fungal infection&#46; We hypothesize the possibility of a donor-derived infection through the cardiac allograft&#44; since the cause of the donor&#39;s death was a road traffic trauma with severe hemothorax which required the insertion of chest tubes at the site of the accident under non-aseptic conditions&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Pericardial effusion occurs frequently in the setting of OHT and has been observed in up to 35&#37; of patients in the immediate postoperative period&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> Although this complication appears to be benign&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> close echocardiographic monitoring is required to rule out the progression to cardiac tamponade&#46; In our patient&#44; pericardial effusion did not spontaneously resolve during the first weeks and pericardiocentesis became mandatory in order to obtain an etiologic diagnosis&#46; The present case exemplifies that both pericardial fluid and pericardiectomy specimens should be sent routinely for microbiological investigation even in the absence of apparent infection&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Current guidelines state that treatment of <span class="elsevierStyleItalic">Candida</span> pericarditis should include amphotericin B&#44; an echinocandin&#44; or fluconazole&#44; in combination with either a pericardial window or pericardiectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Although Puius and Scully<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> reported a favorable outcome using combination therapy with caspofungin and fluconazole&#44; we chose L-AmB followed by step-down to oral fluconazole as the regimen most often employed in the previous&#44; albeit limited&#44; literature&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Paucity of data precludes firm recommendations about the length of treatment&#44; which should continue for several months until complete resolution of pericardial inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Source of funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">M&#46; Fernandez Ruiz enjoys a &#8220;Contract Research Training&#8221; Rio Hortega &#40;CM11&#47;00187&#41; of the Health Institute &#8220;Carlos III&#8221;&#46;</p></span></span>"
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Correspondence
Constrictive pericarditis due to Candida albicans: An unexpected cause of pericardial effusion after heart transplantation
Pericarditis constrictiva por Candida albicans: una causa inesperada de derrame pericárdico tras el trasplante cardíaco
M.J. Ruiz-Canoa,b, M. Fernández-Ruizc,
Autor para correspondencia
mario_fdezruiz@yahoo.es

Corresponding author.
, V. Sáncheza,b, F. López-Medranoc
a Unidad de Insuficiencia Cardíaca y Trasplante, Servicio de Cardiología, Hospital Universitario “12 de Octubre”. Instituto de Investigación Hospital “12 de Octubre” (i+12), Madrid, Spain
b Red de Investigación en Insuficiencia Cardiaca (REDINSCOR), Madrid, Spain
c Unidad de Enfermedades Infecciosas. Hospital Universitario “12 de Octubre”. Instituto de Investigación Hospital “12 de Octubre” (i+12), Madrid, Spain

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