{"id":1178,"date":"2017-01-31T20:36:07","date_gmt":"2017-01-31T19:36:07","guid":{"rendered":"http:\/\/www.newslab.sk\/2017\/01\/31\/invazivna-aspergiloza-u-pacientov-s-pokrocilou-cirhozou-pecene\/"},"modified":"2017-10-04T14:27:11","modified_gmt":"2017-10-04T12:27:11","slug":"invasive-aspergillosis-in-patients-with-advanced-liver-cirrhosis","status":"publish","type":"post","link":"https:\/\/www.newslab.sk\/en\/invasive-aspergillosis-in-patients-with-advanced-liver-cirrhosis\/","title":{"rendered":"Invasive Aspergillosis in Patients with Advanced Liver Cirrhosis"},"content":{"rendered":"<pre><strong><span style=\"color: #ff0000;\">*All tables, charts, graphs and pictures that are featured in this article can be found in the .pdf\u00a0\r\nattachment at the end of the paper.\r\n\r\n<\/span><\/strong><\/pre>\n<p><strong>\u00da<\/strong><strong>vod<\/strong><\/p>\n<p>Aspergil\u00f3za je jedna z naj\u010dastej\u0161\u00edch invaz\u00edvnych mykotick\u00fdch infekci\u00ed u pacientov a vykazuje celkovo st\u00fapaj\u00facu incidenciu\u00a0 (1, 2). Rizikov\u00fa skupinu tvoria hlavne imunokompromitovan\u00ed \u00a0pacienti. T\u00ed predstavuj\u00fa vzh\u013eadom na vzrastaj\u00faci po\u010det transplant\u00e1ci\u00ed kostnej drene a in\u00fdch org\u00e1nov, zav\u00e1dzanie intenzifikovan\u00fdch chemoterapeutick\u00fdch \u00a0a imunosupres\u00edvnych re\u017eimov a HIV pand\u00e9miu st\u00e1le v\u00fdznamnej\u0161iu \u00a0skupinu v popul\u00e1cii \u00a0(3, 4). Invaz\u00edvna aspergil\u00f3za sa vyskytuje hlavne u neutropenick\u00fdch pacientov, zvy\u0161uje sa v\u0161ak aj po\u010det hl\u00e1sen\u00ed u neneutropenick\u00fdch pacientov. Patria sem hlavne pacienti s p\u013e\u00facnymi chorobami, ale aj pacienti s chorobami pe\u010dene \u00a0(3, 5, 6). \u00damrtnos\u0165 \u00a0na invaz\u00edvnu aspergil\u00f3zu \u00a0dosahuje \u00a0v priemere\u00a046 \u2013 63 % a je najvy\u0161\u0161ia u pacientov po transplant\u00e1cii kostnej drene a u HIV\u00a0pozit\u00edvnych \u00a0pacientov \u00a0(1, 3, 5).<\/p>\n<p>Aspergilov\u00e9 kon\u00eddie sa vzh\u013eadom na ich \u010dast\u00fa pr\u00edtomnos\u0165 v ovzdu\u0161\u00ed dost\u00e1vaj\u00fa do tela predov\u0161etk\u00fdm inhal\u00e1ciou. N\u00e1sledne doch\u00e1dza u imunokompromitovan\u00fdch pacientov pre oslaben\u00fa obrann\u00fa funkciu ich slizn\u00edc ku koloniz\u00e1cii p\u013e\u00fac a rastu h\u00fdf. Rast\u00face \u00a0h\u00fdfy, ktor\u00e9 unikn\u00fa obrann\u00fdm mechanizmom hostite\u013ea, dok\u00e1\u017eu penetrova\u0165 cez endoteli\u00e1lnu v\u00fdstelku do cievneho \u00a0rie\u010diska, odkia\u013e sa ich fragmenty krvnou cestou dost\u00e1vaj\u00fa do vzdialen\u00fdch org\u00e1nov. Angioinv\u00e1zia \u00a0vedie \u00a0k trombotiz\u00e1cii \u00a0a ischemiz\u00e1cii postihnut\u00fdch org\u00e1nov, pri\u010dom rozpadaj\u00face sa nekrotick\u00e9 tkanivo je vhodn\u00fdm prostred\u00edm \u00a0na mykotick\u00fd rast (7, 8).<\/p>\n<p>Diseminovan\u00e1 aspergil\u00f3za vr\u00e1tane aspergil\u00f3zy centr\u00e1lnej nervovej s\u00fastavy (CNS) sa vyvinie u menej ako 10 % postihnut\u00fdch pacientov. \u00damrtnos\u0165 v tejto skupine \u00a0je v\u0161ak ve\u013emi vysok\u00e1 a v pr\u00edpade postihnutia CNS sa bl\u00ed\u017ei k 100 %. Cerebr\u00e1lna \u00a0aspregil\u00f3za \u00a0naj\u010dastej\u0161ie \u00a0postihuje \u00a0front\u00e1lny lalok a cerebelopont\u00ednny uhol a iba zriedka je jedinou lokaliz\u00e1ciou disemin\u00e1cie \u00a0(1, 3, 9, 10).<\/p>\n<p>V tomto \u010dl\u00e1nku prezentujeme pr\u00edpady dvoch pacientov s cirh\u00f3zou pe\u010dene, u ktor\u00fdch bola pitvou dok\u00e1zan\u00e1 invaz\u00edvna aspergil\u00f3za s infiltr\u00e1ciou CNS.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>O<\/strong><strong>pi<\/strong><strong>s pr\u00edpadu<\/strong><\/p>\n<p><em>Pr\u00edpad 1<\/em><\/p>\n<p>58-ro\u010dn\u00fd pacient s anamn\u00e9zou cirh\u00f3zy pe\u010dene etyltoxickej gen\u00e9zy Child-Pough C, s ezofage\u00e1lnymi \u00a0varixmi, chronickou \u00a0pankreatit\u00eddou a diabetom druh\u00e9ho typu bol prijat\u00fd na intern\u00fa kliniku pre nieko\u013eko dn\u00ed trvaj\u00face celkov\u00e9 zhor\u0161enie stavu, such\u00fd ka\u0161e\u013e, apatiu, spavos\u0165, dezorient\u00e1ciu, zm\u00e4tenos\u0165 a odmietanie peror\u00e1lneho pr\u00edjmu. Tri t\u00fd\u017edne pred aktu\u00e1lnou hospitaliz\u00e1ciou bol prepusten\u00fd z intern\u00e9ho \u00a0oddelenia \u00a0inej kliniky, na ktor\u00fa bol prijat\u00fd pre dekompenzovan\u00fa cirh\u00f3zu pe\u010dene s ikterom a na ktorej mu bola pred prepusten\u00edm za\u010dat\u00e1 peror\u00e1lna kortikoterapia.<\/p>\n<p>Pri vy\u0161etren\u00ed bol pacient ikterick\u00fd, mal mierne zv\u00fd\u0161en\u00fa teplotu (37,7 \u02daC), vykazoval spomalen\u00e9 psychomotorick\u00e9 \u00a0tempo, bol somnolentn\u00fd, pri postoji a ch\u00f4dzi boli pr\u00edtomn\u00e9 titub\u00e1cie. Fyzik\u00e1lne vy\u0161etrenie p\u013e\u00fac odhalilo obojstranne \u00a0inspira\u010dn\u00e9 chr\u00f4pky. Akcia srdca bola pravideln\u00e1, na EKG bola pr\u00edtomn\u00e1 ascendentn\u00e1 depresia ST segmentu vo zvodoch \u00a0V4 \u2013 V6 a negat\u00edvna vlna T vo zvodoch III, V1 a V3. V laborat\u00f3rnom \u00a0obraze dominovali elevovan\u00e9 hepat\u00e1lne ukazovatele s hyperbilirubin\u00e9miou a zv\u00fd\u0161enou hodnotou\u00a0 amoniaku na 83 \u00b5mol\/l, bol pr\u00edtomn\u00fd hypokoagula\u010dn\u00fd stav,\u00a0trombocytop\u00e9nia \u00a0\u0165a\u017ek\u00e9ho stup\u0148a a zn\u00e1mky dehydrat\u00e1cie. Taktie\u017e boli elevovan\u00e9 z\u00e1palov\u00e9 parametre s hodnotou CRP 62 mg\/l a neutrof\u00edliou.<\/p>\n<p>R\u00f6ntgenologick\u00e9 vy\u0161etrenie p\u013e\u00fac odhalilo obojstrann\u00e9 nehomog\u00e9nne zatienenie v dolnom \u00a0p\u013e\u00facnom \u00a0poli, na \u013eavej strane s dutinovou l\u00e9ziou ve\u013ekosti 25 x 20 mm. Tento n\u00e1lez bol klinicky uzavret\u00fd ako suspektn\u00e1 z\u00e1palov\u00e1 infiltr\u00e1cia. Pacientovi bola pod\u00e1van\u00e1 kombinovan\u00e1 \u00a0parenter\u00e1lna antibiotick\u00e1 terapia a komplexn\u00e1 lie\u010dba vaskul\u00e1rnej a metabolickej dekompenz\u00e1cie cirh\u00f3zy pe\u010dene. Po\u010das hospitaliz\u00e1cie doch\u00e1dzalo \u00a0k postupnej \u00a0progresii poruchy vedomia, ktor\u00e1 bola vzh\u013eadom na z\u00e1kladn\u00e9 ochorenie pripisovan\u00e1 hepat\u00e1lnej encefalopatii, po trojd\u0148ovej hospitaliz\u00e1cii pacient exitoval\u00a0Pri pitve boli pr\u00edtomn\u00e9 viacer\u00e9 n\u00e1lezy zhodn\u00e9 s klinick\u00fdmi diagn\u00f3zami. Makroskopick\u00e9 a histologick\u00e9 \u00a0vy\u0161etrenie odhalilo akt\u00edvnu mikronodul\u00e1rnu cirh\u00f3zu pe\u010dene s ascitom v objeme 500 ml, ezofage\u00e1lnymi \u00a0varixmi a chronickou \u00a0fibrotizuj\u00facou pankreatit\u00eddou a hypertenzn\u00fa chorobu s hypertenzn\u00fdm srdcom a arteriolosklerotickou nefroskler\u00f3zou\u00a0Najv\u00fdraznej\u0161\u00ed n\u00e1lez bol pozorovan\u00fd na hrudnom komplexe. P\u013e\u00faca boli obojstranne \u00a0v\u00fdrazne zv\u00e4\u010d\u0161en\u00e9, v\u013eavo dosahovali hmotnos\u0165 \u00a0750 g a vpravo 950 g. Na pleure sa nach\u00e1dzali tmavo\u010derven\u00e9 \u00a0petechie. Vo\u00a0v\u0161etk\u00fdch lalokoch p\u013e\u00fac boli pr\u00edtomn\u00e9 \u00a0spl\u00fdvaj\u00face lo\u017eisk\u00e1 konsolid\u00e1cie sivoru\u017eovej farby, ktor\u00fdch rezn\u00e1 plocha \u00a0bola such\u00e1 \u00a0a zrnit\u00e1. V oblastiach patologicky zmenen\u00e9ho \u00a0tkaniva sa nach\u00e1dzali viacer\u00e9 cystick\u00e9 dutiny priemeru 4 mm \u2013 2 cm, ohrani\u010den\u00e9 bledohnedou membr\u00e1nou hr\u00fabky\u00a01 \u2013 2 mm. Tieto dutiny boli opticky pr\u00e1zdne, pr\u00edpadne obsahovali mal\u00e9 mno\u017estvo \u017eltosiv\u00e9ho materi\u00e1lu. (obr\u00e1zok \u00a01a). Mikroskopick\u00e9 vy\u0161etrenie patologicky zmenen\u00fdch \u00a0lo\u017e\u00edsk odhalilo absceduj\u00facu \u00a0bronchopneum\u00f3niu s pr\u00edtomn\u00fdmi \u00a0po\u010detn\u00fdmi \u00a0vl\u00e1knit\u00fdmi \u0161trukt\u00farami, ktor\u00e9 vyp\u013a\u0148ali alveoly a tapetovali steny makroskopicky pr\u00edtomn\u00fdch \u00a0cystick\u00fdch \u00fatvarov. Vl\u00e1knit\u00e9 \u0161trukt\u00fary boli septovan\u00e9 \u00a0a vetvili sa pod ostr\u00fdm uhlom, vykazovali PAS pozitivitu, farbili sa striebriacimi technikami a pri farben\u00ed hematoxyl\u00ednom a eoz\u00ednom \u00a0vykazovali v\u00fdrazn\u00fa bazof\u00edliu, \u010d\u00edm korelovali s morfol\u00f3giou aspergil\u00f3zy (obr\u00e1zok 1b).<\/p>\n<p>Pri disekcii ostatn\u00fdch \u00a0vn\u00fatorn\u00fdch \u00a0org\u00e1nov \u00a0sme pozorovali viacer\u00e9 podobn\u00e9 gu\u013eovit\u00e9, pomerne \u00a0ostro ohrani\u010den\u00e9 \u00a0lo\u017eisk\u00e1 ru\u017eovo\u010dervenej farby v \u0161t\u00edtnej \u017e\u013eaze, v k\u00f4re obli\u010diek obojstranne a v tele \u017eal\u00fadka s exulcer\u00e1ciou sliznice. Po\u010detn\u00e9 lo\u017eisk\u00e1 boli pr\u00edtomn\u00e9 aj v myokarde \u013eavej komory srdca. Histologicky \u00a0boli v\u0161etky lo\u017eisk\u00e1 tvoren\u00e9 \u00a0nekroticky zmenen\u00fdm tkanivom prest\u00fapen\u00fdm leukocytov\u00fdm infiltr\u00e1tom s pr\u00edtomn\u00fdmi vl\u00e1knit\u00fdmi vetviacimi sa \u0161trukt\u00farami vo vn\u00fatri ciev s ich mas\u00edvnym prestupom do nekrotick\u00e9ho tkaniva. Najd\u00f4le\u017eitej\u0161\u00ed \u00a0n\u00e1lez bol pr\u00edtomn\u00fd \u00a0na reze mozgu. Po\u010detn\u00e9, neostro ohrani\u010den\u00e9 gu\u013eovit\u00e9 lo\u017eisk\u00e1 ru\u017eovo\u010dervenej farby priemeru 5 mm \u2013 1,5 cm sa nach\u00e1dzali v bielej hmote front\u00e1lneho, pariet\u00e1lneho a okcipit\u00e1lneho \u00a0laloka a v oblasti ponsu. Lo\u017eisk\u00e1 priemeru 2 cm sa nach\u00e1dzali v okol\u00ed zadn\u00e9ho rohu bo\u010dnej komory, v prednej \u010dasti corpus callosum a v \u013eavej hemisf\u00e9re \u00a0mozo\u010dka, zasahuj\u00fac do vermis cerebelli. Histologicky bolo tkanivo mozgu v oblasti lo\u017e\u00edsk edemat\u00f3zne, prest\u00fapen\u00e9 erytrocytmi a granulocytmi a pri farben\u00ed striebriacimi technikami \u00a0sa aj v t\u00fdchto lo\u017eisk\u00e1ch vizualizovali vl\u00e1knit\u00e9 vetviace sa huby.<\/p>\n<p>N\u00e1lezy zisten\u00e9 pri pitve odhalili diseminovan\u00fa invaz\u00edvnu aspergil\u00f3zu s mas\u00edvnym postihnut\u00edm centr\u00e1lneho nervov\u00e9ho syst\u00e9mu.<\/p>\n<p>&nbsp;<\/p>\n<p><em>Pr\u00edpad 2<\/em><\/p>\n<p>49-ro\u010dn\u00e1 pacientka bola prijat\u00e1 na \u0161pecializovan\u00e9 hepatologick\u00e9 pracovisko \u00a0internej \u00a0kliniky pre ak\u00fatnu alkoholov\u00fa hepatit\u00eddu v ter\u00e9ne cirh\u00f3zy pe\u010dene Child-Pough C. Po\u010das \u00a0hospitaliz\u00e1cie \u00a0jej bola nasaden\u00e1 parenter\u00e1lna kortikoterapia v trvan\u00ed troch t\u00fd\u017ed\u0148ov.<\/p>\n<p>Pri v y\u0161etren\u00ed bola pacientka pri vedom\u00ed, \u00a0ikterick\u00e1, \u00a0s pr\u00edtomn\u00fdm\u00a0\u201eflapping\u201c tremorom a ascitom. D\u00fdchanie bolo obojstranne \u010dist\u00e9, baz\u00e1lne oslaben\u00e9. \u00a0Pri biochemickom \u00a0vy\u0161etren\u00ed s\u00e9ra dominovali zv\u00fd\u0161en\u00e9 hepat\u00e1lne parametre s hyperbilirubin\u00e9miou a hodnotou amoniaku\u00a033,3 \u00b5mol\/l, ktor\u00fd po\u010das hospitaliz\u00e1cie st\u00fapol na 80 \u00b5mol\/l. Bol pr\u00edtomn\u00fd hypokoagula\u010dn\u00fd stav, mierna trombocytop\u00e9nia a stredne \u0165a\u017ek\u00e1 an\u00e9mia. Po\u010das hospitaliz\u00e1cie sa postupne zvy\u0161ovali z\u00e1palov\u00e9 markery s hodnotou CRP do 39,34 mg\/l a s neutrof\u00edliou.<\/p>\n<p>Na r\u00f6ntgene p\u013e\u00fac sa zobrazilo spl\u00fdvav\u00e9 zatienenie v \u013eavom strednom a\u017e dolnom p\u013e\u00facnom \u00a0poli. Na CT hrudn\u00edka bol op\u00edsan\u00fd bilater\u00e1lny fluidotorax s dystelekt\u00e1zami a nepravideln\u00e9 mapovit\u00e9 alveolovo-interstici\u00e1lne z\u00f3ny v\u013eavo ve\u013ekosti do 35 mm a vpravo do 13 mm. V \u013eavom hornom p\u013e\u00facnom poli v ter\u00e9ne dystelektatick\u00e9ho parench\u00fdmu \u00a0v kombin\u00e1cii so z\u00e1palov\u00fdmi zmenami \u00a0bolo pr\u00edtomn\u00e9 drobn\u00e9 lo\u017eisko plynu. Pri bronchoskopii \u00a0bol\u00a0v hlavn\u00fdch bronchoch \u00a0pozorovan\u00fd \u017elt\u00fd hnis. Pacientke bola vysaden\u00e1 kortikoterapia a za\u010dat\u00e1 intenz\u00edvna oxygenoterapia, dychov\u00e1 rehabilit\u00e1cia a kombinovan\u00e1 antibiotick\u00e1 terapia.<\/p>\n<p>Pre progresiu p\u013e\u00facneho n\u00e1lezu bola pacientka po mesa\u010dnej hospitaliz\u00e1cii prelo\u017een\u00e1\u00a0 na jednotku intenz\u00edvnej starostlivosti kliniky pneumol\u00f3gie a ftizeol\u00f3gie. Pri pr\u00edjme bola pacientka objekt\u00edvne afebriln\u00e1, tachypnoick\u00e1, somnolentn\u00e1, spav\u00e1, odpovedala \u00a0adekv\u00e1tne, av\u0161ak nie zrozumite\u013ene. D\u00fdchanie bolo v\u013eavo v celom rozsahu oslaben\u00e9 a\u017e vymiznut\u00e9, vpravo boli baz\u00e1lne po\u010dute\u013en\u00e9 \u00a0jemn\u00e9 vrzoty. Hospitaliz\u00e1cia pacientky sa komplikovala vznikom \u013eavostrann\u00e9ho tenzn\u00e9ho pneumotoraxu, ktor\u00fd bol n\u00e1sledne dr\u00e9novan\u00fd aj s 1 500 ml s\u00e9rosangvinolentn\u00e9ho v\u00fdpotku. Napriek komplexnej lie\u010dbe sa stav pacientky zhor\u0161oval, prehlbovala sa kvantitat\u00edvna porucha vedomia a po troch d\u0148och hospitaliz\u00e1cie zomrela.<\/p>\n<p>Pitva odhalila akt\u00edvnu mikronodul\u00e1rnu steatocirh\u00f3zu pe\u010dene a ascites v objeme 1 500 ml. V pleur\u00e1lnej dutine sa obojstranne nach\u00e1dzalo 500 ml sangvinolentnej \u00a0tekutiny. P\u013e\u00faca boli tuh\u0161ej konzistencie so zv\u00fd\u0161enou hmotnos\u0165ou, ktor\u00e1 v\u013eavo dosahovala 630 gramov a vpravo a\u017e 790 gramov.<\/p>\n<p>V hrote \u013eav\u00e9ho horn\u00e9ho laloka p\u013e\u00fac bolo pr\u00edtomn\u00e9 neostro ohrani\u010den\u00e9 sivo\u017elt\u00e9 tuh\u0161ie lo\u017eisko priemeru 8 cm, ktor\u00e9 bolo na reze \u010diasto\u010dne skolikvovan\u00e9 a vyplnen\u00e9 hustou sivo\u017eltou tekutinou. Na reze prav\u00e9ho doln\u00e9ho laloka p\u013e\u00fac, siahaj\u00fac a\u017e po pleuru sa nach\u00e1dzalo konsolidovan\u00e9 ru\u017eovosiv\u00e9 lo\u017eisko priemeru 6 cm, miestami sa ka\u0161ovito rozpad\u00e1vaj\u00face.<\/p>\n<p>Histologicky boli lo\u017eisk\u00e1 tvoren\u00e9 nahromaden\u00fdmi polymorfonukle\u00e1rnymi granulocytmi s rozpadom alveol\u00e1rnych sept, lemovan\u00e9 granula\u010dn\u00fdm tkanivom. Pleura v okol\u00ed lo\u017e\u00edsk vykazovala zn\u00e1mky \u00a0fibrin\u00f3zno-hnisavej pleurit\u00eddy. V lo\u017eisk\u00e1ch sa taktie\u017e nach\u00e1dzali po\u010detn\u00e9 \u00a0PAS pozit\u00edvne septovan\u00e9 vetviace sa h\u00fdfy, ktor\u00e9 sa farbili striebriacimi technikami \u00a0a ich obraz s\u00fahlasil s morfol\u00f3giou aspergil\u00f3zy.<\/p>\n<p>Ne\u010dakan\u00fd n\u00e1lez odhalila pitva mozgu, kde sa vo front\u00e1lnom laloku pravej hemisf\u00e9ry parasagit\u00e1lne nach\u00e1dzalo \u00a0pomerne \u00a0ostro ohrani\u010den\u00e9 lo\u017eisko priemeru 5 cm, na reze \u017eltosivej farby, ka\u0161ovitej konzistencie (obr\u00e1zok 2a). M\u00e4kk\u00e9 pleny nad lo\u017eiskom boli zhrubnut\u00e9 \u00a0a zakalen\u00e9. Identick\u00e9 lo\u017eisko men\u0161\u00edch rozmerov sa nach\u00e1dzalo zrkadlovo parasagit\u00e1lne na \u013eavej strane. Bo\u010dn\u00e9 komory boli po narezan\u00ed vyplnen\u00e9 mierne zakalen\u00fdm mozgovomiechov\u00fdm mokom. Mikroskopicky boli lo\u017eisk\u00e1 tvoren\u00e9 nekrotick\u00fdm detritom a v\u00fdrazne prest\u00fapen\u00e9 polymorfonukle\u00e1rnymi granulocytmi, na perif\u00e9rii bol zv\u00fdraznen\u00fd ed\u00e9m a mal\u00e9 mno\u017estvo zrnie\u010dkov\u00fdch buniek. Z\u00e1palov\u00fd infiltr\u00e1t prestupoval \u00a0aj do m\u00e4kk\u00fdch plien, ktor\u00e9 boli v\u00e4zivovo zhrubnut\u00e9. Impregn\u00e1ciou \u00a0striebrom a farben\u00edm PAS sa v cievach \u00a0zobrazili vl\u00e1knit\u00e9 vetviace sa huby, ktor\u00e9 prestupovali do okolit\u00e9ho parench\u00fdmu (obr\u00e1zok 2b).<\/p>\n<p>Tento n\u00e1lez pouk\u00e1zal na invaz\u00edvnu aspergil\u00f3zu s disemin\u00e1ciou do cen- tr\u00e1lneho nervov\u00e9ho syst\u00e9mu v podobe abscesov a lo\u017eiskovej meningit\u00eddy.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Dis<\/strong><strong>k<\/strong><strong>usia<\/strong><\/p>\n<p>Invaz\u00edvna aspergil\u00f3za sa zara\u010fuje medzi oport\u00fanne infekcie, ktor\u00e9 postihuj\u00fa predov\u0161etk\u00fdm neutropenick\u00fdch pacientov. Do skupiny nekonven\u010dn\u00fdch pacientov, ktor\u00ed m\u00f4\u017eu by\u0165 postihnut\u00ed generalizovanou infekciou, sa zara\u010fuj\u00fa aj pacienti s ochoreniami pe\u010dene, a to hlavne pacienti s cirh\u00f3zou pe\u010dene v \u0161t\u00e1diu Child-Pough \u00a0C a pacienti s ak\u00fatnym zlyhan\u00edm pe\u010dene. Ke\u010f\u017ee nejde o klasick\u00fa rizikov\u00fa skupinu, typick\u00fa pre dan\u00fa chorobu, je aspergil\u00f3za u t\u00fdchto pacientov \u010dasto diagnostikovan\u00e1 a\u017e v pokro\u010dil\u00fdch \u0161t\u00e1di\u00e1ch, ke\u010f u\u017e terapia nem\u00e1 tak\u00fa \u00faspe\u0161nos\u0165 (6).<\/p>\n<p>U zdrav\u00fdch jedincov s\u00fa kon\u00eddie, \u00a0ktor\u00e9 sa dostan\u00fa do d\u00fdchac\u00edch ciest, odstra\u0148ovan\u00e9 fagocyt\u00e1rnou \u010dinnos\u0165ou alveol\u00e1rnych makrof\u00e1gov. Makrof\u00e1gy iniciuj\u00fa z\u00e1palov\u00fa odpove\u010f sprostredkovan\u00fa neutrofiln\u00fdmi polymorfonukle\u00e1rnymi granulocytmi. Kon\u00eddie, ktor\u00e9 unikn\u00fa makrof\u00e1gom, sa premenia na h\u00fdfy a tie s\u00fa prim\u00e1rne odstra\u0148ovan\u00e9 neutrofilmi (7).<\/p>\n<p>Pacienti s cirh\u00f3zou pe\u010dene vykazuj\u00fa dysfunkciu retikuloendoteli\u00e1lneho syst\u00e9mu, zn\u00ed\u017een\u00fa mobiliz\u00e1ciu neutrofilov a ich zn\u00ed\u017een\u00fa fagocyt\u00e1rnu funkciu (11). Taktie\u017e sa predpoklad\u00e1, \u017ee hyperamon\u00e9mia a hyponatri\u00e9mia, ktor\u00e9 s\u00fa u cirhotick\u00fdch pacientov pomerne \u010dast\u00e9, zni\u017euj\u00fa fagocyt\u00e1rnu schop- nos\u0165 neutrofilov a zvy\u0161uj\u00fa ich spont\u00e1nny \u00a0rozpad \u00a0(12). Imunodeficienciu cirhotick\u00fdch \u00a0pacientov \u00a0ovplyv\u0148uj\u00fa aj pridru\u017een\u00e9\u00a0 faktory, ako je malnutr\u00edcia, s\u00fa\u010dasn\u00e9 po\u017e\u00edvanie alkoholu, \u010dastej\u0161ie podstupovanie \u00a0invaz\u00edvnych proced\u00far a indik\u00e1cia kortikosteroidovej terapie.<\/p>\n<p>Pacienti s cirh\u00f3zou \u00a0vykazuj\u00fa v\u0161eobecne \u00a0v\u00e4\u010d\u0161ie riziko be\u017en\u00fdch, ako aj oport\u00fannych \u00a0infekci\u00ed. Toto \u00a0riziko sa e\u0161te zvy\u0161uje u hospitalizovan\u00fdch pacientov, u ktor\u00fdch m\u00f4\u017ee dosahova\u0165 a\u017e 34 % oproti 7 % v be\u017enej popul\u00e1cii hospitalizovan\u00fdch pacientov. Infekcie u cirhotick\u00fdch pacientov zodpovedaj\u00fa za pribli\u017ene 30 % \u00famrt\u00ed v ich skupine (11).<\/p>\n<p>Pr\u00edznaky invaz\u00edvnej aspergil\u00f3zy s\u00fa v\u0161eobecne \u00a0ne\u0161pecifick\u00e9, tak isto ako aj biochemick\u00e9 \u00a0markery z\u00e1palu, ako C-reakt\u00edvny prote\u00edn a prokalciton\u00edn. Na mo\u017enos\u0165 tejto infekcie upozorn\u00ed zv\u00e4\u010d\u0161a a\u017e negat\u00edvna odpove\u010f na antibiotick\u00fa terapiu (13). Medzi z\u00e1kladn\u00e9 met\u00f3dy, ktor\u00e9 sa uplat\u0148uj\u00fa v diagnostike invaz\u00edvnej aspergil\u00f3zy na z\u00e1klade revidovan\u00fdch odpor\u00fa\u010dan\u00ed IDSA (Infectious Diseases Society of America) z roku 2016, patr\u00ed simult\u00e1nne histopatologick\u00e9 a kultiva\u010dn\u00e9 \u00a0vy\u0161etrenie \u00a0vhodn\u00fdch \u00a0vzoriek, ktor\u00e9 je v ur\u010dit\u00fdch pr\u00edpadoch doplnen\u00e9 molekul\u00e1rnymi vy\u0161etrovac\u00edmi met\u00f3dami. Rutinne sa vyu\u017e\u00edva detekcia dvoch mykotick\u00fdch biomarkerov, a to detekcia antig\u00e9nu galaktomananu zo s\u00e9ra alebo bronchoalveol\u00e1rnej \u00a0lav\u00e1\u017ee, pr\u00edpadne \u00a0detekcia antig\u00e9nu (1-3)-beta-D-gluk\u00e1nu. Monitorovanie s\u00e9rov\u00fdch hodn\u00f4t antig\u00e9nu galaktomananu sa m\u00f4\u017ee tie\u017e vyu\u017ei\u0165 na sledovanie pacientovej odpovede na terapiu (13, 14, 15). D\u00f4le\u017eit\u00fa \u00a0skupinu v r\u00e1mci skorej diagnostiky predstavuj\u00fa zobrazovacie techniky. Odpor\u00fa\u010da sa CT vy\u0161etrenie p\u013e\u00fac, v\u017edy ke\u010f je pr\u00edtomn\u00e9 \u00a0klinick\u00e9 podozrenie \u00a0na invaz\u00edvnu aspegil\u00f3zu, bez oh\u013eadu na v\u00fdsledky r\u00f6ntgenologick\u00e9ho vy\u0161etrenia. Pou\u017eitie kontrastu v r\u00e1mci CT sa odpor\u00fa\u010da, len ak sa podozriv\u00e9 lo\u017eisk\u00e1 nach\u00e1dzaj\u00fa v bl\u00edzkosti v\u00e4\u010d\u0161ej cievy. Invaz\u00edvna aspergil\u00f3za \u00a0sa v p\u013e\u00facach \u00a0naj\u010dastej\u0161ie prezentuje pr\u00edtomnos\u0165ou viacpo\u010detn\u00fdch makronodulov (zatienenia, ktor\u00fdch priemer je viac ako 1 cm), \u010dast\u00e1 je tie\u017e pr\u00edtomnos\u0165 tzv. \u201ehalo\u201c znaku, ke\u010f sa okolo makronodulu zobrazuje kruhov\u00e9 hmlist\u00e9 zatienenie. Okrem toho m\u00f4\u017eu by\u0165 pr\u00edtomn\u00e9 mnoh\u00e9 \u010fal\u0161ie ne\u0161pecifick\u00e9 zmeny, ako napr\u00edklad l\u00e9zie charakteru infarktu, kavit\u00e1rne l\u00e9zie, tzv. \u201eair-crescent\u201c znak (pr\u00edtomnos\u0165 vzduchu tvaru polmesia- ca vo vn\u00fatri nodulu), pleur\u00e1lny v\u00fdpotok alebo zhluk mal\u00fdch nodulov (14, 16).<\/p>\n<p>\u010co sa t\u00fdka aspergil\u00f3zy centr\u00e1lnej nervovej s\u00fastavy, m\u00f4\u017ee sa prezento- va\u0165 ak\u00fatnym n\u00e1stupom lo\u017eiskov\u00e9ho neurologick\u00e9ho deficitu, vznikaj\u00faceho v d\u00f4sledku cievnej alebo rozp\u00ednaj\u00facej sa l\u00e9zie. Medzi \u010fal\u0161ie \u010dast\u00e9 sympt\u00f3my patr\u00ed zmena vedomia, boles\u0165 \u00a0hlavy, vracanie, hemipar\u00e9za, dysartria, letargia a z\u00e1chvatov\u00e9 stavy. Na jej diagnostiku sa odpor\u00fa\u010da \u00a0MRI vy\u0161etrenie, pri ktorom sa v\u00e4\u010d\u0161inou aspergilov\u00e9 abscesy javia ako hypointenzn\u00e9 \u00a0lo\u017eisk\u00e1 pri T1 v\u00e1\u017eenom obraze s nepr\u00edtomn\u00fdm alebo minim\u00e1lnym zv\u00fdraznen\u00edm postkontrastne, ktor\u00e9 sa d\u00e1va do s\u00favisu s rozsahom okolit\u00e9ho z\u00e1palu. Pri T2 v\u00e1\u017eenom obraze s\u00fa l\u00e9zie v\u00e4\u010d\u0161inou olemovan\u00e9 prstencom n\u00edzkej intenzity sp\u00f4soben\u00fdm \u00a0s\u010dasti krv\u00e1can\u00edm, s\u010dasti pr\u00edtomnos\u0165ou \u017eeleza, magn\u00e9zia a mang\u00e1nu v mykotick\u00fdch lo\u017eisk\u00e1ch a hust\u00fdm usporiadan\u00edm h\u00fdf na perif\u00e9rii lo\u017e\u00edsk. Krv\u00e1canie sa v lo\u017eisk\u00e1ch zobrazuje v asi 25 % pr\u00edpadov (17, 18).<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Z<\/strong><strong>\u00e1<\/strong><strong>ver<\/strong><\/p>\n<p>Invaz\u00edvna aspergil\u00f3za b\u00fdva vzh\u013eadom \u00a0na skuto\u010dnos\u0165, \u017ee cirh\u00f3za ne-patr\u00ed medzi klasick\u00e9 rizikov\u00e9 faktory jej vzniku, \u010dasto poddiagnostikovan\u00e1. Naj\u010dastej\u0161ie b\u00fdvaj\u00fa postihnut\u00ed pacienti v pokro\u010dilom \u0161t\u00e1diu cirh\u00f3zy pe\u010dene alebo pacienti s ak\u00fatnym pe\u010de\u0148ov\u00fdm zlyhan\u00edm. Klinick\u00e9 pr\u00edznaky s\u00fa \u010dasto nev\u00fdrazn\u00e9, kultiva\u010dn\u00e9 vy\u0161etrenia poskytn\u00fa len limitovan\u00e9 inform\u00e1cie a zobrazovacie diagnostick\u00e9 metodiky s\u00fa zv\u00e4\u010d\u0161a ne\u0161pecifick\u00e9. Mortalita nelie\u010den\u00fdch pacientov s invaz\u00edvnou aspergil\u00f3zou \u00a0je vysok\u00e1. Pr\u00ed\u010dinou smrti b\u00fdva naj\u010dastej\u0161ie generalizovan\u00e1 aspergil\u00f3za a postihnutie CNS. Zaradenie cirhotick\u00fdch pacientov medzi rizikov\u00e9 skupiny tejto infekcie m\u00f4\u017ee dopom\u00f4c\u0165 k jej v\u010dasnej\u0161ej diagn\u00f3ze a adekv\u00e1tnej lie\u010dbe, \u010do m\u00f4\u017ee vies\u0165 k zn\u00ed\u017eeniu mortality v d\u00f4sledku aspergilov\u00fdch infekci\u00ed u t\u00fdchto pacientov \u00a0(19, 20).<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p><strong>L<\/strong><strong>it<\/strong><strong>e<\/strong><strong>ra<\/strong><strong>t<\/strong><strong>\u00fa<\/strong><strong>ra<\/strong><\/p>\n<p><strong>1<\/strong><strong>. <\/strong>Graf K, Khani S, Ott E, et al. Five-years surveillance of invasive aspergillosis \u00a0in a university hospital. <em>BM<\/em><em>C Infect <\/em><em>D<\/em><em>i<\/em><em>s<\/em>. 2011;11(1).<\/p>\n<p><strong>2<\/strong><strong>. <\/strong>Groll A, Shah P, Mentzel C, et al. Trends in the post mortem epidemiology of invasive fun<\/p>\n<p>gal infections at a University Hospital. <em>J<\/em><em>o<\/em><em>urna<\/em><em>l <\/em><em>o<\/em><em>f Infection<\/em>. 1996;33(1):23\u201332.<\/p>\n<p><strong>3<\/strong><strong>. <\/strong>Lin S, Schranz J, Teutsch S. Aspergillosis Case-Fatality Rate: Systematic \u00a0Review of the Literatu <em>Clinical Infectious \u00a0<\/em><em>D<\/em><em>i<\/em><em>s<\/em><em>e<\/em><em>a<\/em><em>s<\/em><em>e<\/em><em>s<\/em>. 2001;32(3):358\u2013366.<\/p>\n<p><strong>4<\/strong><strong>. <\/strong>Maschmeyer G, Haas A, Cornely O. Invasive Aspergillosis: epidemiology, diagnosis and\u00a0management of immunocompromised \u00a0patient. <em>D<\/em><em>r<\/em><em>u<\/em><em>g<\/em><em>s<\/em>. 2007;67(11):1567\u20131601.<\/p>\n<p><strong>5<\/strong><strong>. <\/strong>Cornet M, Fleury L, Maslo C, et al. Epidemiology of invasive aspergillosis in France: a six-year multicentric survey in the Greater Paris area. <em>J<\/em><em>o<\/em><em>urna<\/em><em>l of Hospital <\/em><em>I<\/em><em>n<\/em><em>f<\/em><em>e<\/em><em>c<\/em><em>t<\/em><em>io<\/em><em>n<\/em>. 2002;51(4):288\u2013296.<\/p>\n<p><strong>6<\/strong><strong>. <\/strong>Cornillet A, Camus C, Nimubona S, et al. Comparison \u00a0of Epidemiological, Clinical, and Biological Features of Invasive Aspergillosis in Neutropenic \u00a0and Nonneutropenic Patients: A 6 Year Survey. <em>Clinical Infectious <\/em><em>D<\/em><em>i<\/em><em>s<\/em><em>e<\/em><em>a<\/em><em>s<\/em><em>e<\/em><em>s<\/em>. 2006;43(5):577\u2013584.<\/p>\n<p><strong>7<\/strong><strong>. <\/strong>Dagenais T, Keller N. Pathogenesis of Aspergillus fumigatus \u00a0in Invasive Aspergillosis.\u00a0<em>Clinical Microbiology <\/em><em>R<\/em><em>e<\/em><em>vi<\/em><em>e<\/em><em>w<\/em><em>s<\/em>. 2009;22(3):447\u2013465.<\/p>\n<p><strong>8<\/strong><strong>. <\/strong>Kamai Y, Lossinsky A, Liu H, et al. Polarized response of endothelial cells to invasion by Aspergillus fumigatus. <em>C<\/em><em>ellula<\/em><em>r <\/em><em>M<\/em><em>i<\/em><em>c<\/em><em>r<\/em><em>o<\/em><em>b<\/em><em>i<\/em><em>o<\/em><em>l<\/em><em>og<\/em><em>y<\/em>. 2009;11(1):170\u2013182.<\/p>\n<p><strong>9<\/strong><strong>. <\/strong>Denning D. Invasive Aspergillosis. <em>Clinical Infectious <\/em><em>D<\/em><em>i<\/em><em>s<\/em><em>e<\/em><em>a<\/em><em>s<\/em><em>e<\/em><em>s<\/em>. 1998;26(4):781\u2013803.<\/p>\n<p><strong>1<\/strong><strong>0<\/strong><strong>. <\/strong>Schwartz S, Ruhnke M, Ribaud P, et al. Improved outcome in central nervous system aspergillosis, using voriconazole treatment. <em>Bl<\/em><em>o<\/em><em>o<\/em><em>d<\/em>. 2005;106(8):2641\u20132645.<\/p>\n<p><strong>1<\/strong><strong>1<\/strong><strong>. <\/strong>Bonnel A, Bunchorntavakul C, Reddy K. Immune Dysfunction and Infections in Patients\u00a0with Cirrhosis. <em>Clinical Gastroenterology <\/em><em>an<\/em><em>d Hepatology<\/em>. 2011;9(9):727\u2013738.<\/p>\n<p><strong>1<\/strong><strong>2<\/strong><strong>. <\/strong>Shawcross D, Wright G, Stadlbauer V, et al. Ammonia impairs neutrophil phagocytic function in liver diseas <em>H<\/em><em>e<\/em><em>p<\/em><em>a<\/em><em>t<\/em><em>o<\/em><em>l<\/em><em>og<\/em><em>y<\/em>. 2008;48(4):1202\u20131212.<\/p>\n<p><strong>1<\/strong><strong>3<\/strong><strong>. <\/strong>Barton R. Laboratory Diagnosis of Invasive Aspergillosis: From Diagnosis to Prediction of<\/p>\n<p>Outcome. <em>S<\/em><em>ci<\/em><em>e<\/em><em>n<\/em><em>tifi<\/em><em>c<\/em><em>a<\/em>. 2013;2013:1\u201329.<\/p>\n<p><strong>1<\/strong><strong>4<\/strong><strong>. <\/strong>Patterson T, Thompson G, Denning D, et al. Practice Guidelines \u00a0for the Diagnosis and Management \u00a0of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. <em>Clin Infect <\/em><em>D<\/em><em>i<\/em><em>s<\/em>. 2016;63(4):e1\u2013e60.<\/p>\n<p><strong>1<\/strong><strong>5<\/strong><strong>. <\/strong>Ambasta A, Carson J, Church D. The use of biomarkers and molecular methods for the earlier diagnosis of invasive aspergillosis in immunocompromised \u00a0patients. <em>Me<\/em><em>d Myco<\/em>. 2015;53(6):531\u2013557.<\/p>\n<p><strong>1<\/strong><strong>6<\/strong><strong>. <\/strong>Greene R, Schlamm H, Oestmann J, et al. Imaging Findings in Acute Invasive Pulmonary Aspergillosis: Clinical Significance of the Halo Sign. <em>Clinical Infectious <\/em><em>D<\/em><em>i<\/em><em>s<\/em><em>e<\/em><em>a<\/em><em>ses<\/em>. 2007;44(3):373\u2013379.<\/p>\n<p><strong>1<\/strong><strong>7<\/strong><strong>. <\/strong>Almutairi B, Nguyen T, Jansen G, et al. Invasive Aspergillosis of the Brain: Radiologic-Patho-<\/p>\n<p>logic Correlation1. <em>R<\/em><em>ad<\/em><em>i<\/em><em>o<\/em><em>G<\/em><em>r<\/em><em>a<\/em><em>ph<\/em><em>i<\/em><em>c<\/em><em>s<\/em>. 2009;29(2):375\u2013379.<\/p>\n<p><strong>1<\/strong><strong>8<\/strong><strong>. <\/strong>Marzolf G, Sabou M, Lannes B, et al. Magnetic Resonance Imaging of Cerebral Aspergil- losis: Imaging and Pathological \u00a0Correlations. <em>P<\/em><em>L<\/em><em>O<\/em><em>S <\/em><em>O<\/em><em>N<\/em><em>E<\/em>. 2016;11(4):e0152475.<\/p>\n<p><strong>1<\/strong><strong>9<\/strong><strong>. <\/strong>Jeurissen S, Vogelaers D, Sermijn \u00a0E, et al. Invasive Aspergillosis \u00a0in Patients \u00a0with \u00a0Cirrhosis, a Case Report and Review of the Last 10 Years. <em>A<\/em><em>c<\/em><em>t<\/em><em>a \u00a0Clinica \u00a0<\/em><em>B<\/em><em>el<\/em><em>gi<\/em><em>c<\/em><em>a<\/em>. 2013;68(5):368\u2013375.<\/p>\n<p><strong>2<\/strong><strong>0<\/strong><strong>. <\/strong>Falcone M, Massetti A, Russo A, et al. Invasive aspergillosis in patients with liver diseas<\/p>\n","protected":false},"excerpt":{"rendered":"<p>*All tables, charts, graphs and pictures that are featured in this article can be found in the .pdf\u00a0 attachment at the end of the paper. \u00davod Aspergil\u00f3za je jedna z naj\u010dastej\u0161\u00edch invaz\u00edvnych mykotick\u00fdch infekci\u00ed u pacientov a vykazuje celkovo st\u00fapaj\u00facu incidenciu\u00a0 (1, 2). Rizikov\u00fa skupinu tvoria hlavne imunokompromitovan\u00ed \u00a0pacienti. T\u00ed predstavuj\u00fa vzh\u013eadom na vzrastaj\u00faci po\u010det<\/p>\n","protected":false},"author":7,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_mi_skip_tracking":false,"footnotes":""},"categories":[297],"tags":[768,766,765,769,767],"class_list":["post-1178","post","type-post","status-publish","format-standard","hentry","category-pathology","tag-aspergillosis-of-central-nervous-system","tag-disseminated-aspergillosis","tag-invasive-aspergillosis","tag-liver-cirrhosis","tag-opportunistic-infection","typ_clanku-casuistry"],"acf":{"abstrakt":"<p><strong>Introduction: <\/strong>Invasive aspergillosis (IA) belongs among the most frequent invasive mycotic\/fungal infections and represents a serious problem in the group of immunocompromised patients. However, in recent years, the number of reports of infections increases also in non-neutropenic patients, particularly in relation to pulmonary and hepatic diseases.<\/p>\n<p><strong>Methodology: <\/strong>We demonstrate the cases of two patients with liver cirrhosis at the Child-Pough C-stage, who showed worsening inflammatory parameters with neutrophilia during hospitalisation. Imaging technology showed inflammatory infiltrates with cavity lesions in the pulmonary area. Despite the wide-range antibiotic therapy, progressive quantitative loss of consciousness occurred in both patients and subsequently they expired. The autopsy in both cases disclosed ascending bronchopneumonia with dissemination into central nervous system and in one case disclosed also wide-spread dissemination also to other organs. Samples from tissue with pathological change were examined microscopically with a basic histological staining by haematoxylin-eosin, special PAS staining (periodic-acid-Shiff) and impregnating silver methodology (methenamine silver).<\/p>\n<p><strong>Result: <\/strong>The histological picture of examined samples showed vessels and surrounding tissue with fibrillary septated structures branching under sharp angle. The given structures showed PAS positivity, were stained with silver techniques and when stained with haematoxylin-eosin, they showed significant basophilia, thus correlating with morphology of aspergillosis.<\/p>\n<p><strong>Conclusion: <\/strong>IA is often under-diagnosed in patients with liver diseases resulting in high subsequent mortality as this is not a typical risk group of patients for this disease. It mainly affects the patients in advanced stage of cirrhosis or with acute liver failure. Clinical symptoms are often non-significant and non-specific, culturing tests provide only limited information. Including IA into differential diagnosis of complications in patients with chronic liver diseases may contribute to earlier diagnosis and adequate treatment.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Key words: <\/strong>invasive aspergillosis, disseminated aspergillosis, opportunistic infection, aspergillosis of central nervous system, liver cirrhosis<\/p>\n","casopis":[{"ID":991,"post_author":"7","post_date":"2017-02-01 09:43:42","post_date_gmt":"2017-02-01 08:43:42","post_content":"<ul>\r\n \t<li>Pulmonary aspergillosis<\/li>\r\n \t<li>Infections caused by cytomegalovirus \u2013 diagnosis and therapy<\/li>\r\n \t<li>Long-term molecular remission as a precondition for successful pregnancy in patients with chronic myelocyte leukemia<\/li>\r\n \t<li>Chromosome 11 aberrations in a patient with acute myeloid leukemia \u2013 a case study<\/li>\r\n \t<li>New biomarkers in diagnosing IgA nephropathy<\/li>\r\n<\/ul>","post_title":"newslab","post_excerpt":"","post_status":"publish","comment_status":"closed","ping_status":"closed","post_password":"","post_name":"newslab-2016-02","to_ping":"","pinged":"","post_modified":"2017-08-16 21:36:48","post_modified_gmt":"2017-08-16 19:36:48","post_content_filtered":"","post_parent":0,"guid":"http:\/\/www.newslab.sk\/casopis\/newslab-2016-02\/","menu_order":0,"post_type":"casopis","post_mime_type":"","comment_count":"0","filter":"raw"}],"strana":"121","upload_clanok":{"ID":1179,"id":1179,"title":"Newslab_2_2016_Invaz\u00edvna aspergil\u00f3za u pacientov s pokro\u010dilou","filename":"Newslab_2_2016_Invaz\u00edvna-aspergil\u00f3za-u-pacientov-s-pokro\u010dilou.pdf","filesize":375231,"url":"https:\/\/www.newslab.sk\/wp-content\/uploads\/2017\/01\/Newslab_2_2016_Invaz\u00edvna-aspergil\u00f3za-u-pacientov-s-pokro\u010dilou.pdf","link":"https:\/\/www.newslab.sk\/en\/invasive-aspergillosis-in-patients-with-advanced-liver-cirrhosis\/newslab_2_2016_invazivna-aspergiloza-u-pacientov-s-pokrocilou\/","alt":"","author":"7","description":"","caption":"","name":"newslab_2_2016_invazivna-aspergiloza-u-pacientov-s-pokrocilou","status":"inherit","uploaded_to":1178,"date":"2017-02-01 19:28:12","modified":"2017-02-01 19:28:12","menu_order":0,"mime_type":"application\/pdf","type":"application","subtype":"pdf","icon":"https:\/\/www.newslab.sk\/wp-includes\/images\/media\/document.png"}},"_links":{"self":[{"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/posts\/1178","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/users\/7"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/comments?post=1178"}],"version-history":[{"count":0,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/posts\/1178\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/media?parent=1178"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/categories?post=1178"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/tags?post=1178"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}