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en nuestra serie <span class="elsevierStyleItalic">Candida</span> spp&#46; seguido de <span class="elsevierStyleItalic">A&#46; fumigatus</span> fueron los agentes etiol&#243;gicos asociados a la presencia de empiema f&#250;ngico con una tasa de mortalidad discretamente inferior&#46; Todos los pacientes salvo uno presentaban una o varias patolog&#237;as previas que compromet&#237;an su sistema inmunitario seg&#250;n los est&#225;ndares ya publicados<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a>&#58; enfermedad neopl&#225;sica&#44; diabetes mellitus&#44; tratamiento con esteroides de larga duraci&#243;n&#44; cirrosis hep&#225;tica&#44; trasplante de &#243;rgano s&#243;lido&#44; alcoholismo&#44; infecci&#243;n por el virus de la inmunodeficiencia humana o cirug&#237;a en las 4 semanas previas al aislamiento f&#250;ngico&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">La sospecha cl&#237;nica&#44; el drenaje de la cavidad tor&#225;cica&#44; el inicio temprano y el tratamiento de larga duraci&#243;n con antif&#250;ngicos se asocian a la reducci&#243;n de la tasa de mortalidad<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a>&#46; Sin embargo&#44; el tratamiento del empiema f&#250;ngico no est&#225; protocolizado y se pueden utilizar combinaciones que incluyen varios f&#225;rmacos &#40;voriconazol&#44; anfotericina B y equinocandinas&#41; debido a la variabilidad de penetrancia de los antif&#250;ngicos sist&#233;micos a nivel pleural<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; El porcentaje de pacientes tratados con antibioterapia de amplio espectro fue superior al de pacientes tratados con antimic&#243;ticos&#44; a pesar de la demostraci&#243;n etiol&#243;gica&#44; sin desescalamiento posterior de aquellos&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">La ausencia de un tratamiento antif&#250;ngico espec&#237;fico puede ser debida a la falta de consideraci&#243;n por parte del cl&#237;nico de los hongos como pat&#243;genos verdaderos&#46; Resulta necesario valorar su papel infeccioso y estudiar de forma individualizada cada caso con la finalidad de optimizar el tratamiento&#46; Esto incluye la necesidad de profilaxis farmacol&#243;gica en pacientes de alto riesgo para el desarrollo de empiema f&#250;ngico &#40;hemodi&#225;lisis&#44; reexploraci&#243;n quir&#250;rgica postrasplante&#44; colonizaci&#243;n ambiental por <span class="elsevierStyleItalic">Aspergillus</span> o infecci&#243;n documentada por citomegalovirus&#41;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">No deber&#237;a pasarse por alto la gravedad de esta entidad infravalorada y sus consecuencias devastadoras en los pacientes&#46;</p></span>"
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Carta científica
Empiema fúngico: una entidad infrecuente con elevada mortalidad
Fungal Empyema: An Uncommon Entity With High Mortality
Blanca de Vega Sáncheza,
Corresponding author
blancadevegasanchez@gmail.com

Autor para correspondencia.
, Irene López Ramosb, Raúl Ortiz de Lejarazub, Carlos Disdier Vicentea,c
a Servicio de Neumología, Hospital Clínico Universitario de Valladolid, Valladolid, España
b Servicio de Microbiología, Hospital Clínico Universitario de Valladolid, Valladolid, España
c CIBERES (Centro de Investigación en Red Enfermedades Respiratorias), Valladolid, España
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Se aislaron 7 levaduras &#40;2 de ellas <span class="elsevierStyleItalic">Candida</span> no <span class="elsevierStyleItalic">albicans</span>&#41; y 3 <span class="elsevierStyleItalic">Aspergillus fumigatus &#40;A&#46; fumigatus&#41;</span>&#44; no document&#225;ndose resistencias&#46; La tasa total de tratamiento antimic&#243;tico fue del 55&#37;&#44; habiendo sido empleados de forma predominante derivados az&#243;licos y con un uso minoritario de caspofungina o anfotericina B liposomal inhalada&#46; Ninguno de los pacientes hab&#237;a recibido profilaxis antif&#250;ngica antes del episodio analizado&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se reflejan los factores de riesgo identificados en cada paciente para desarrollar infecci&#243;n f&#250;ngica y la especie aislada en cada caso&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Al igual que en otras series con mayor n&#250;mero de casos<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;2</span></a>&#44; en nuestra serie <span class="elsevierStyleItalic">Candida</span> spp&#46; seguido de <span class="elsevierStyleItalic">A&#46; fumigatus</span> fueron los agentes etiol&#243;gicos asociados a la presencia de empiema f&#250;ngico con una tasa de mortalidad discretamente inferior&#46; Todos los pacientes salvo uno presentaban una o varias patolog&#237;as previas que compromet&#237;an su sistema inmunitario seg&#250;n los est&#225;ndares ya publicados<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a>&#58; enfermedad neopl&#225;sica&#44; diabetes mellitus&#44; tratamiento con esteroides de larga duraci&#243;n&#44; cirrosis hep&#225;tica&#44; trasplante de &#243;rgano s&#243;lido&#44; alcoholismo&#44; infecci&#243;n por el virus de la inmunodeficiencia humana o cirug&#237;a en las 4 semanas previas al aislamiento f&#250;ngico&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">La sospecha cl&#237;nica&#44; el drenaje de la cavidad tor&#225;cica&#44; el inicio temprano y el tratamiento de larga duraci&#243;n con antif&#250;ngicos se asocian a la reducci&#243;n de la tasa de mortalidad<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a>&#46; Sin embargo&#44; el tratamiento del empiema f&#250;ngico no est&#225; protocolizado y se pueden utilizar combinaciones que incluyen varios f&#225;rmacos &#40;voriconazol&#44; anfotericina B y equinocandinas&#41; debido a la variabilidad de penetrancia de los antif&#250;ngicos sist&#233;micos a nivel pleural<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; El porcentaje de pacientes tratados con antibioterapia de amplio espectro fue superior al de pacientes tratados con antimic&#243;ticos&#44; a pesar de la demostraci&#243;n etiol&#243;gica&#44; sin desescalamiento posterior de aquellos&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">La ausencia de un tratamiento antif&#250;ngico espec&#237;fico puede ser debida a la falta de consideraci&#243;n por parte del cl&#237;nico de los hongos como pat&#243;genos verdaderos&#46; Resulta necesario valorar su papel infeccioso y estudiar de forma individualizada cada caso con la finalidad de optimizar el tratamiento&#46; Esto incluye la necesidad de profilaxis farmacol&#243;gica en pacientes de alto riesgo para el desarrollo de empiema f&#250;ngico &#40;hemodi&#225;lisis&#44; reexploraci&#243;n quir&#250;rgica postrasplante&#44; colonizaci&#243;n ambiental por <span class="elsevierStyleItalic">Aspergillus</span> o infecci&#243;n documentada por citomegalovirus&#41;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">No deber&#237;a pasarse por alto la gravedad de esta entidad infravalorada y sus consecuencias devastadoras en los pacientes&#46;</p></span>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cirug&#237;a previa &#40;esofaguectom&#237;a&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>alcoholismo &#43; neoplasia s&#243;lida &#40;carcinoma epidermoide es&#243;fago&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cirug&#237;a previa &#40;gastrectom&#237;a total&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>neoplasia s&#243;lida &#40;g&#225;strica&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Candida albicans</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cirug&#237;a previa &#40;bari&#225;trica&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Candida albicans</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trasplante cardiaco<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>diabetes mellitus 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Aspergillus fumigatus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neoplasia hematol&#243;gica &#40;s&#237;ndrome mielodispl&#225;sico&#41; &#43; diabetes mellitus 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Aspergillus fumigatus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cirug&#237;a previa &#40;toracotom&#237;a lateral&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>alcoholismo&#43; enfermedad pulmonar obstructiva cr&#243;nica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Aspergillus fumigatus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Article information
ISSN: 03002896
Original language: Spanish
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