Impaired
Clearance
and Organ Localization in Obstructive Jaundice
of Cundidu albicans
By Schmuel Katz, Glenn J. Merkel, Walter J. Folkening, Raoul S. Rosenthal, and Jay L. Grosfeld Indianapolis, Indiana and Fort Wayne, Indiana l Sepsis is a major cause of morbidity and mortality in infants with cholestatic jaundice. This may be attributed to altered host defense mechanisms. Fungal infection frequently occurs in immunocompromised patients. This study evaluates the effect of biliary obstruction on blood clearance and organ localization of radiolabeled viable Candida albicans. Male Sprague-Dawley rats (140 to 150 g) were placed in 2 groups. Group I (n = 30) were sham-operated controls. Group II (n = 90) underwent ligation and division of the distal common bile duct (CDL). At 1.2, and 3 weeks following CDL, lo7 cells/ml radiolabeled viable C albicans were injected via the tail vein. The final distribution of the organisms was calculated and-expressed as the mean percent of radiolabeled organisms per gram and per total organ. Blood clearance of C a/l&ens was similarly rapid in both groups. However, there was a significant decrease in the trapping of fungi by the rat liver Kupffer cells (20.3% & 7.9% Y control 42.5% ? 15%; P > .OOl), and increased pulmonary localization of bacteria 3 weeks following CDL (53.6% f 13.2% v control 41.4% 4 6.4%). The significant decrease in liver trapping and increased lung localization of Calbicans in CDL rats, may result in systemic reemergence of fungi and play a role in the susceptibility to fungal infection in jaundiced subjects. Copyright o 1991 by W.B. Saunders Company INDEX WORDS:
Obstructive
jaundice, sepsis.
R
ECENTLY, Can&u al&cans has become a significant cause of morbidity and mortality in immunocompromised patients,’ postoperative patients,2,3 and low birth-weight premature neonates.4 Since the advent of long-term intravenous catheterization and total parenteral nutrition (TPN), frequent and prolonged use of broad-spectrum antibiotics, and immunosuppressive chemotherapy, disseminated candidiasis occurs more frequently in the clinical setting. In the pediatric age group, patients with TPN cholestasis are more susceptible to systemic bacterial and fungal infection.5’6 It has been suggested that fungi are killed and ingested by circulating neutrophils and From the Section of Pediatric Surgery, Department of Surgery, and the Department of Microbiology and Immunology, Indiana University School of Medicine, and the James Whitcomb Riley Hospital for Children, Indianapolis, IN and Fort Wayne, IN. Presented at the Jens G. Rosenkrantz Resident Competition at the 42nd Annual Meeting of the Surgical Section of the American Academy of Pediatrics, Boston, Massachusetts, October 6-7, 1990. Address reprint requests to Jay L. Grosfeld, MD, Surgeon-in-Chief .I.W Riley Hospital for Children, 702 Bamhill Dr (k-21 ), Indianapolis, IN 46202-5200. Copyright o 1991 by W.B. Saunders Company 0022-3468/9112608-0005$03.00/0
904
tissue macrophages. The role of the reticuloendothelial system (RES) of the liver in removing bacteria, endotoxins, platelets, fibrin, and other particulate matter has been thoroughly investigated. In contrast, there is a paucity of knowledge concerning the fate of blood-borne yeasts as would be encountered during fungemia.7,s This study evaluates clearance and organ localization of C ulbicuns in normal rats and those with obstructive jaundice. MATERIALS AND METHODS
Experimental Animals One hundred twenty male Sprague-Dawley rats (Harlan SD Inc. Indianapolis, IN) weighing 140 to 150 g were housed four per cage and fed with standard Rodent Laboratory Chow (no. 5001; Purina Mills Inc, St Louis, MO) and tap water ad libitum. Laparotomy was performed under 0.1 mL per rat intramuscular (IM) ketamine cocktail anesthesia (containing 100 mg of ketamine, 2.2 mg of promazine, and 0.4 mg of atropine per milliliter). Rats were placed in two experimental groups: group I (n = 30) sham-operated controls, underwent mobilization of the hepatoduodenal ligament; group II (n = 90) had ligation and division of the common bile duct (CDL) between small titanium clips (Ethicon Inc, Somerville, NJ).
Preparation of Radiolabeled Yeasts Clinical isolate of C albicans (Indiana University Hospital, Indianapolis, IN) were inoculated in Yeast Nitrogen Base (Difco Laboratories, Detroit, MI) (containing 0.25% glucose, 0.5% (NH&SO, and 2 pCi of L-[4,5-3H] Leucine per milliliter; Amersham Corp, Arlington Heights, IL). These cultured fungi were incubated at 37°C on a rotary shaker (200 rpm) for 10 hours to late exponential-early stationary phase. Yeast were harvested and washed 2 times with 0.9% NaCl, resuspended, and microscopically counted with a hemocytometer. The final concentration was adjusted to 1 to 3 x 10’ yeasts/ml. Samples of the final suspension were taken for radioactivity determination prior to their use. Typically, the specific activity of ‘H was 1 dpm per 100 to 1,000 cells.
Blood Clearance and Organ Localization of C ulbicuns For fungal challenge, clearance, and organ localization, the animals were sedated with an intramuscular injection of ketamine cocktail and kept in a restraining cage. The tail was soaked in warm water (50°C) and cleansed. One milliliter of 3H-labeled C albicans was injected via a lateral tail vein using a Butterfly infusion set (27 x )/sg, &in tubing, no. 4995; Abbott Hospitals Inc, North Chicago, IL). To evaluate blood clearance of Candida, the tail was transected and 50 JLL of blood was obtained using heparinized micropipettes at 1, 5, and 10 minutes following fungal challenge. Blood samples were transferred to glass scintillation vials. At 1, 4, and 24 hours following intravenous (IV) injection of fungi, the liver spleen, kidneys, and lungs were removed and weighed. Small samples (50 to 100 mg) were collected in vials. Blood and tissue
Journal ofPediatric Surgery, Vol26, No 8 (August), 1991: pp
904-907
905
IMPAIRED CLEARANCE OF CANDIDA ALBICANS
samples were dissolved by treatment in 1 mL of 100% Soluene 350 (Packard Camberra Co, Downers Grove, IL) tissue solubilizer, overnight at 50°C. The dissolved tissues were dried by 100% isopropyl alcohol and decolorized by 30% H,O, for 30 minutes. Samples were cooled to room temperature and 1 mL of SN HCl and 1.5 mL of Insta-Gel R-F scintillation fluid were added. Radioactivity was determined using 2200 CA Tricarb liquid scintillation analyzer (Packard Instrument Co, Downers Grove, IL) interfaced with an IBM microcomputer. Data were corrected for quench using a calibration curve determined by external standardization for ‘H and radioactivity was expressed as dpm per gram tissue and per organ.
9b DPMlORGAN 80 il 50 40 30 20 10 0 SPLEEN
LIVER
Fig 2.
Comparative
LUNG
KIDNEY
liver, spleen, kidney and lung localization of
intravenously injected Calbicans in control (U) and in CDL rats 1 (D). 2 (0). and 3 weeks (8) following operation. Values represent mean 2 SD expressed as % of the injected fungi per totaf organ (%dpm/ organ). Note a significant decrease in liver uptake and a compensatory increase in lung localization of fungi at 3 weeks following operation.
Statistical Analysis Values were expressed as the mean lr: percentage of the injected organisms and analyzed for validity using the unpaired Student’s ? test.
RESULTS
Intravenous injection of viable radiolabeled C albicans was followed by immediate clearance from the blood (more than 95% at 5 minutes) and subsequent localization of fungi in the different organs. At 1 hour following injection, the liver and the lungs are the main trapping organs of Candida: 42.5% + 15% and 41.4% + 6.1%, respectively. The spleen had 4.48% ? 0.9% and the kidneys 1.58% & 0.32% of the injected fungi. The organ distribution of C albicans at 1,4, and 24 hours following fungal injection is shown in Fig 1. Fungal localization in rats 1 and 2 weeks following CDL were similar to the controls. However, at 3 weeks following CDL there was a decrease in the ability of the liver to trap fungi when compared with controls (Fig 2). Liver localization of Candida was significantly reduced at 1, 4, and 24 hours following injection (Fig 3). The impaired trapping of fungi by the liver was partially compensated by an increase in lung localization of C albicans (Fig 4). %DPM/ORGAN
DISCUSSION The commonly cited risk factors associated with systemic candidiasis in neonates include prematurity, very low birth weight, prolonged antibiotic therapy, and the presence of long-term intravascular catheters, especially when used for TE’N.4 Some of these factors (prematurity, low birth weight, sepsis) may also contribute to the development of TPN-induced cholestasis.5’6 Obstructive jaundice predisposes to bacterial sepsis in humans and animal models?-13 In a previous study, Katz et al demonstrated that biliary obstruction by CDL results in a significant decrease in hepatic phagocytosis of viable Escherichia coli.‘4 This hepatic phagocytic dysfunction was partially compensated by increased lung localization of bacteria. It should be emphasized that in contrast to the typical distribution of E coli (more than 70% of the bacteria are cleared by the liver and about 1.5% by the lung), yeast are almost equally cleared by the lungs (41%) and the liver (42%) at the first hour following injection. The different distribution pattern of these
I
,oo-i.‘l
L-----z
%DPM/ORGAN 1
60 60
40
20
n 1
H&R
4 H&S
24 HOURS
Fig 1. Comparative liver (W), lung (a), spleen (0). and kidney (D) localization of IV injected viable radiolabeled Calbicans at 1,4, and 24 hours following injection. Values represent mean % of injected fungi per total organ (%dpm/organ). Initially, the lung and liver are the major trapping organs. Note a decrease in lung localization of h7did8 in the first 4 hours. There is a decrease in total organ localization of fungi at 24 hours.
1
24
2
HO&S Fig 3. Comparative liver localization of C dbicuns in controls (D) and in CDL rats (m) at 3 weeks following CDL. Note a significant decrease in liver uptake of fungi at 1, 2, 4, and 24 hours following injection in CDL rats.
KATZET AL %DPM/ORGAN
1
Fig 4.
Comparative
2
24
lung localization of C elbicans
in the control
(Ef) and CDL (ml groups at 3 weeks following operation. Note a significant increase in lung uptake of radlolabeled fungi at 1,2,4. and 24 hours following injection. At 24 hours, 9.1% f 2.7% of the injected radiolabeled material is still present in the lung of CDL rats (control, 3.6% ? 1.3%; P < .OOl).
two organisms may be due to the difference in their size (bacteria 1.0 pm and Candida approximately 5.0 pm). Although Candida has a greater initial affinity for the lungs, the radiolabeled material representing viable or fragmented fungi is subsequently removed from the lungs and resides in the liver. At 24 hours, 20% of the injected radiolabeled Candida particles are located in the liver and 3% in the lung. The histological changes in liver of CDL rats consisted of periductal inflammation and fibrosis, which may increase the parenchymal pressure and, therefore, may result in decreased sinusoidal blood flow.14-17 This may affect the initial rate as well as the late phase of fungal clearance by the liver. At 24 hours, 13% of the
Candida are still located in the lungs (control, 3%) (Fig 1). The mechanism by which the decreased liver trapping of yeasts results in an increase in lung localization of both bacteria and fungi has not been clarified. Lanser and Saba” showed that neutrophil margination in the lung occurs immediately following RES blockade and may contribute to the increase in lung localization of viable bacteria. We have previously demonstrated that prolonged CDL in rats results in thickening of the lung interstitium, consisting of histiocytes and vascular-lining macrophages that could enhance lung localization of particulate matter.14 The lung is a very efficient trapping organ; however, its ability to kill sequestrated fungi is still questionable, Furthermore, the presence of viable yeasts or even fragmented fungi in the lung, associated with the release of hydrolytic, proteolytic, and lipolytic enzymes, may cause a severe local inflammatory reaction, formation of microabscesses, and even larger areas of tissue necrosis.’ Therefore, failure of the RES of the liver observed in rats following CDL may result in an increased rate of local lung infection and pulmonary complications with potential risk for reemergence of fungi and systemic infection. These data indicate that cholestatic jaundice should be considered as an additional risk factor influencing the development of systemic candidiasis. Premature infants with low birth weight, receiving prolonged TPN, who develop cholestasis may have an increased risk for developing morbid and potentially lethal systemic candidiasis.
REFERENCES 1. Myerowitz RL, Pazin GJ, Allen CM: Disseminated candidiasis. Changes in incidence, underlying diseases and pathology. Am 3 Clin Path01 68:29-38,1977 2. Marsh PK, Tally FP, Kellum J, et al: Cundidu infections in surgical patients. Ann Surg 198:42-47,1982 3. Solomkin JS, Flohr AM, Simmons RL: Indications for therapy for fungemia in postoperative patients. Arch Surg 117:12731275,1982 4. Butler KM, Baker CJ: Cundida: An increasing important pathogen in the nursery. Pediatr Clin North Am 35:543-563,1988 5. Pereira GR, Sherman MS, DiGiacomo J, et al: Hyperalimentation-induced cholestasis. Am J Dis Child 135:842-8451981 6. Hodes JE, Grosfeld JL, Weber TR, et al: Hepatic failure in infants on totalparenteral nutrition (TPN): Clinical and histopathologic observation. J Pediatr Surg 17:463-468,1982 7. Stone I-III, Kolb LD, Currie CA, et al: Candidu sepsis: Pathogenesis and principles of treatment. Ann Surg 179:697-711, 1974 8. Baine WB, Koenig MG, Goodman JS: Clearance of Candidu albicam from the bloodstream of rabbits. Infect Immun 10:14201425,1974 9. Maggiore G, DiGiacomo C, Scotta M, et al: Cell-mediated immunity in children with chronic cholestasis. J Pediatr Gastroenterol Nutr 1:385-3881982
10. Holman JM, Rikkers LF, Moody FG: Sepsis in the management of complicated biliary disorders. Am J Surg 138809~813,1979 11. Drivas G, James 0, Wandle N: Study of reticuloendothelial phagocytic capacity in patients with cholestasis. Br Med J 1:1.5681569,1976 12. Holman JM, Rikkers LF: Biliary obstruction and host defense failure. J Surg Res 32:208-213,1982 13. Pain JA: Reticuloendothelial function in obstructive jaundice. Br J Surg 74:1091-1094,1987 14. Katz S, Grosfeld JL, Gross K, et al: Impaired bacterial clearance and trapping in obstructive jaundice. Ann Surg 199:1420,1984 1.5. Ryan CJ, Than T, Blumgart LH: Choledochoduodenostomy in the rat with obstructive jaundice. J Surg Res 23:321-331, 1977 16. Goeting NLM, Fleming JS, Gallagher P, et al: Alteration in liver blood flow and reticuloendothelial function in progressive cirrhosis in the rat. J Nucl Med 27:1751-1754,1986 17. Katz S, Yang R, Rodefeld MJ, et al: Impaired hepatic bacterial clearance is reversed by surgical relief of obstructive jaundice. J Pediatr Surg 26:401-406,199l 18. Lanser ME, Saba TM: Neutrophil-mediated lung localization of bacteria: A mechanism of pulmonary injury. Surgery 90:473-481,198l
IMPAIRED
CLEARANCE
OF CANDIDA
ALBICANS
907
Discussion S. Lacey (Chapel Hill, NC): In another study that you presented this morning you demonstrated a significant weight loss in the group of animals with CDL. In this study were the animals’ weights comparable? If the sham group did not have the same degree of weight loss, is it really fair to compare the two groups and say that the decreased liver clearance is secondary to the ligation rather than to malnutrition and resultant immunocompromise? A. Pulito (Lexington, KY): How does the clinical picture of TPN-induced cholestasis in the neonate relate to acute total CDL as produced in your experimental animal?
S. Katz (response): The CDL rats failed to grow but did not lose weight. The sham-operated controls were studied a week following operation. At that time there was no significant difference in weight between the experimental groups. TPN-induced cholestasis is a well-established clinical entity. There is some similarity between our model of acute biliary obstruction and TPN cholestasis. In the first 2 weeks following CDL, there was no significant change in RES function. Prolonged jaundice (3 weeks) with continuous deterioration of liver function resulted in phagocytic dysfunction.
Clearance
and Organ Localization in Obstructive Jaundice
of Cundidu albicans
By Schmuel Katz, Glenn J. Merkel, Walter J. Folkening, Raoul S. Rosenthal, and Jay L. Grosfeld Indianapolis, Indiana and Fort Wayne, Indiana l Sepsis is a major cause of morbidity and mortality in infants with cholestatic jaundice. This may be attributed to altered host defense mechanisms. Fungal infection frequently occurs in immunocompromised patients. This study evaluates the effect of biliary obstruction on blood clearance and organ localization of radiolabeled viable Candida albicans. Male Sprague-Dawley rats (140 to 150 g) were placed in 2 groups. Group I (n = 30) were sham-operated controls. Group II (n = 90) underwent ligation and division of the distal common bile duct (CDL). At 1.2, and 3 weeks following CDL, lo7 cells/ml radiolabeled viable C albicans were injected via the tail vein. The final distribution of the organisms was calculated and-expressed as the mean percent of radiolabeled organisms per gram and per total organ. Blood clearance of C a/l&ens was similarly rapid in both groups. However, there was a significant decrease in the trapping of fungi by the rat liver Kupffer cells (20.3% & 7.9% Y control 42.5% ? 15%; P > .OOl), and increased pulmonary localization of bacteria 3 weeks following CDL (53.6% f 13.2% v control 41.4% 4 6.4%). The significant decrease in liver trapping and increased lung localization of Calbicans in CDL rats, may result in systemic reemergence of fungi and play a role in the susceptibility to fungal infection in jaundiced subjects. Copyright o 1991 by W.B. Saunders Company INDEX WORDS:
Obstructive
jaundice, sepsis.
R
ECENTLY, Can&u al&cans has become a significant cause of morbidity and mortality in immunocompromised patients,’ postoperative patients,2,3 and low birth-weight premature neonates.4 Since the advent of long-term intravenous catheterization and total parenteral nutrition (TPN), frequent and prolonged use of broad-spectrum antibiotics, and immunosuppressive chemotherapy, disseminated candidiasis occurs more frequently in the clinical setting. In the pediatric age group, patients with TPN cholestasis are more susceptible to systemic bacterial and fungal infection.5’6 It has been suggested that fungi are killed and ingested by circulating neutrophils and From the Section of Pediatric Surgery, Department of Surgery, and the Department of Microbiology and Immunology, Indiana University School of Medicine, and the James Whitcomb Riley Hospital for Children, Indianapolis, IN and Fort Wayne, IN. Presented at the Jens G. Rosenkrantz Resident Competition at the 42nd Annual Meeting of the Surgical Section of the American Academy of Pediatrics, Boston, Massachusetts, October 6-7, 1990. Address reprint requests to Jay L. Grosfeld, MD, Surgeon-in-Chief .I.W Riley Hospital for Children, 702 Bamhill Dr (k-21 ), Indianapolis, IN 46202-5200. Copyright o 1991 by W.B. Saunders Company 0022-3468/9112608-0005$03.00/0
904
tissue macrophages. The role of the reticuloendothelial system (RES) of the liver in removing bacteria, endotoxins, platelets, fibrin, and other particulate matter has been thoroughly investigated. In contrast, there is a paucity of knowledge concerning the fate of blood-borne yeasts as would be encountered during fungemia.7,s This study evaluates clearance and organ localization of C ulbicuns in normal rats and those with obstructive jaundice. MATERIALS AND METHODS
Experimental Animals One hundred twenty male Sprague-Dawley rats (Harlan SD Inc. Indianapolis, IN) weighing 140 to 150 g were housed four per cage and fed with standard Rodent Laboratory Chow (no. 5001; Purina Mills Inc, St Louis, MO) and tap water ad libitum. Laparotomy was performed under 0.1 mL per rat intramuscular (IM) ketamine cocktail anesthesia (containing 100 mg of ketamine, 2.2 mg of promazine, and 0.4 mg of atropine per milliliter). Rats were placed in two experimental groups: group I (n = 30) sham-operated controls, underwent mobilization of the hepatoduodenal ligament; group II (n = 90) had ligation and division of the common bile duct (CDL) between small titanium clips (Ethicon Inc, Somerville, NJ).
Preparation of Radiolabeled Yeasts Clinical isolate of C albicans (Indiana University Hospital, Indianapolis, IN) were inoculated in Yeast Nitrogen Base (Difco Laboratories, Detroit, MI) (containing 0.25% glucose, 0.5% (NH&SO, and 2 pCi of L-[4,5-3H] Leucine per milliliter; Amersham Corp, Arlington Heights, IL). These cultured fungi were incubated at 37°C on a rotary shaker (200 rpm) for 10 hours to late exponential-early stationary phase. Yeast were harvested and washed 2 times with 0.9% NaCl, resuspended, and microscopically counted with a hemocytometer. The final concentration was adjusted to 1 to 3 x 10’ yeasts/ml. Samples of the final suspension were taken for radioactivity determination prior to their use. Typically, the specific activity of ‘H was 1 dpm per 100 to 1,000 cells.
Blood Clearance and Organ Localization of C ulbicuns For fungal challenge, clearance, and organ localization, the animals were sedated with an intramuscular injection of ketamine cocktail and kept in a restraining cage. The tail was soaked in warm water (50°C) and cleansed. One milliliter of 3H-labeled C albicans was injected via a lateral tail vein using a Butterfly infusion set (27 x )/sg, &in tubing, no. 4995; Abbott Hospitals Inc, North Chicago, IL). To evaluate blood clearance of Candida, the tail was transected and 50 JLL of blood was obtained using heparinized micropipettes at 1, 5, and 10 minutes following fungal challenge. Blood samples were transferred to glass scintillation vials. At 1, 4, and 24 hours following intravenous (IV) injection of fungi, the liver spleen, kidneys, and lungs were removed and weighed. Small samples (50 to 100 mg) were collected in vials. Blood and tissue
Journal ofPediatric Surgery, Vol26, No 8 (August), 1991: pp
904-907
905
IMPAIRED CLEARANCE OF CANDIDA ALBICANS
samples were dissolved by treatment in 1 mL of 100% Soluene 350 (Packard Camberra Co, Downers Grove, IL) tissue solubilizer, overnight at 50°C. The dissolved tissues were dried by 100% isopropyl alcohol and decolorized by 30% H,O, for 30 minutes. Samples were cooled to room temperature and 1 mL of SN HCl and 1.5 mL of Insta-Gel R-F scintillation fluid were added. Radioactivity was determined using 2200 CA Tricarb liquid scintillation analyzer (Packard Instrument Co, Downers Grove, IL) interfaced with an IBM microcomputer. Data were corrected for quench using a calibration curve determined by external standardization for ‘H and radioactivity was expressed as dpm per gram tissue and per organ.
9b DPMlORGAN 80 il 50 40 30 20 10 0 SPLEEN
LIVER
Fig 2.
Comparative
LUNG
KIDNEY
liver, spleen, kidney and lung localization of
intravenously injected Calbicans in control (U) and in CDL rats 1 (D). 2 (0). and 3 weeks (8) following operation. Values represent mean 2 SD expressed as % of the injected fungi per totaf organ (%dpm/ organ). Note a significant decrease in liver uptake and a compensatory increase in lung localization of fungi at 3 weeks following operation.
Statistical Analysis Values were expressed as the mean lr: percentage of the injected organisms and analyzed for validity using the unpaired Student’s ? test.
RESULTS
Intravenous injection of viable radiolabeled C albicans was followed by immediate clearance from the blood (more than 95% at 5 minutes) and subsequent localization of fungi in the different organs. At 1 hour following injection, the liver and the lungs are the main trapping organs of Candida: 42.5% + 15% and 41.4% + 6.1%, respectively. The spleen had 4.48% ? 0.9% and the kidneys 1.58% & 0.32% of the injected fungi. The organ distribution of C albicans at 1,4, and 24 hours following fungal injection is shown in Fig 1. Fungal localization in rats 1 and 2 weeks following CDL were similar to the controls. However, at 3 weeks following CDL there was a decrease in the ability of the liver to trap fungi when compared with controls (Fig 2). Liver localization of Candida was significantly reduced at 1, 4, and 24 hours following injection (Fig 3). The impaired trapping of fungi by the liver was partially compensated by an increase in lung localization of C albicans (Fig 4). %DPM/ORGAN
DISCUSSION The commonly cited risk factors associated with systemic candidiasis in neonates include prematurity, very low birth weight, prolonged antibiotic therapy, and the presence of long-term intravascular catheters, especially when used for TE’N.4 Some of these factors (prematurity, low birth weight, sepsis) may also contribute to the development of TPN-induced cholestasis.5’6 Obstructive jaundice predisposes to bacterial sepsis in humans and animal models?-13 In a previous study, Katz et al demonstrated that biliary obstruction by CDL results in a significant decrease in hepatic phagocytosis of viable Escherichia coli.‘4 This hepatic phagocytic dysfunction was partially compensated by increased lung localization of bacteria. It should be emphasized that in contrast to the typical distribution of E coli (more than 70% of the bacteria are cleared by the liver and about 1.5% by the lung), yeast are almost equally cleared by the lungs (41%) and the liver (42%) at the first hour following injection. The different distribution pattern of these
I
,oo-i.‘l
L-----z
%DPM/ORGAN 1
60 60
40
20
n 1
H&R
4 H&S
24 HOURS
Fig 1. Comparative liver (W), lung (a), spleen (0). and kidney (D) localization of IV injected viable radiolabeled Calbicans at 1,4, and 24 hours following injection. Values represent mean % of injected fungi per total organ (%dpm/organ). Initially, the lung and liver are the major trapping organs. Note a decrease in lung localization of h7did8 in the first 4 hours. There is a decrease in total organ localization of fungi at 24 hours.
1
24
2
HO&S Fig 3. Comparative liver localization of C dbicuns in controls (D) and in CDL rats (m) at 3 weeks following CDL. Note a significant decrease in liver uptake of fungi at 1, 2, 4, and 24 hours following injection in CDL rats.
KATZET AL %DPM/ORGAN
1
Fig 4.
Comparative
2
24
lung localization of C elbicans
in the control
(Ef) and CDL (ml groups at 3 weeks following operation. Note a significant increase in lung uptake of radlolabeled fungi at 1,2,4. and 24 hours following injection. At 24 hours, 9.1% f 2.7% of the injected radiolabeled material is still present in the lung of CDL rats (control, 3.6% ? 1.3%; P < .OOl).
two organisms may be due to the difference in their size (bacteria 1.0 pm and Candida approximately 5.0 pm). Although Candida has a greater initial affinity for the lungs, the radiolabeled material representing viable or fragmented fungi is subsequently removed from the lungs and resides in the liver. At 24 hours, 20% of the injected radiolabeled Candida particles are located in the liver and 3% in the lung. The histological changes in liver of CDL rats consisted of periductal inflammation and fibrosis, which may increase the parenchymal pressure and, therefore, may result in decreased sinusoidal blood flow.14-17 This may affect the initial rate as well as the late phase of fungal clearance by the liver. At 24 hours, 13% of the
Candida are still located in the lungs (control, 3%) (Fig 1). The mechanism by which the decreased liver trapping of yeasts results in an increase in lung localization of both bacteria and fungi has not been clarified. Lanser and Saba” showed that neutrophil margination in the lung occurs immediately following RES blockade and may contribute to the increase in lung localization of viable bacteria. We have previously demonstrated that prolonged CDL in rats results in thickening of the lung interstitium, consisting of histiocytes and vascular-lining macrophages that could enhance lung localization of particulate matter.14 The lung is a very efficient trapping organ; however, its ability to kill sequestrated fungi is still questionable, Furthermore, the presence of viable yeasts or even fragmented fungi in the lung, associated with the release of hydrolytic, proteolytic, and lipolytic enzymes, may cause a severe local inflammatory reaction, formation of microabscesses, and even larger areas of tissue necrosis.’ Therefore, failure of the RES of the liver observed in rats following CDL may result in an increased rate of local lung infection and pulmonary complications with potential risk for reemergence of fungi and systemic infection. These data indicate that cholestatic jaundice should be considered as an additional risk factor influencing the development of systemic candidiasis. Premature infants with low birth weight, receiving prolonged TPN, who develop cholestasis may have an increased risk for developing morbid and potentially lethal systemic candidiasis.
REFERENCES 1. Myerowitz RL, Pazin GJ, Allen CM: Disseminated candidiasis. Changes in incidence, underlying diseases and pathology. Am 3 Clin Path01 68:29-38,1977 2. Marsh PK, Tally FP, Kellum J, et al: Cundidu infections in surgical patients. Ann Surg 198:42-47,1982 3. Solomkin JS, Flohr AM, Simmons RL: Indications for therapy for fungemia in postoperative patients. Arch Surg 117:12731275,1982 4. Butler KM, Baker CJ: Cundida: An increasing important pathogen in the nursery. Pediatr Clin North Am 35:543-563,1988 5. Pereira GR, Sherman MS, DiGiacomo J, et al: Hyperalimentation-induced cholestasis. Am J Dis Child 135:842-8451981 6. Hodes JE, Grosfeld JL, Weber TR, et al: Hepatic failure in infants on totalparenteral nutrition (TPN): Clinical and histopathologic observation. J Pediatr Surg 17:463-468,1982 7. Stone I-III, Kolb LD, Currie CA, et al: Candidu sepsis: Pathogenesis and principles of treatment. Ann Surg 179:697-711, 1974 8. Baine WB, Koenig MG, Goodman JS: Clearance of Candidu albicam from the bloodstream of rabbits. Infect Immun 10:14201425,1974 9. Maggiore G, DiGiacomo C, Scotta M, et al: Cell-mediated immunity in children with chronic cholestasis. J Pediatr Gastroenterol Nutr 1:385-3881982
10. Holman JM, Rikkers LF, Moody FG: Sepsis in the management of complicated biliary disorders. Am J Surg 138809~813,1979 11. Drivas G, James 0, Wandle N: Study of reticuloendothelial phagocytic capacity in patients with cholestasis. Br Med J 1:1.5681569,1976 12. Holman JM, Rikkers LF: Biliary obstruction and host defense failure. J Surg Res 32:208-213,1982 13. Pain JA: Reticuloendothelial function in obstructive jaundice. Br J Surg 74:1091-1094,1987 14. Katz S, Grosfeld JL, Gross K, et al: Impaired bacterial clearance and trapping in obstructive jaundice. Ann Surg 199:1420,1984 1.5. Ryan CJ, Than T, Blumgart LH: Choledochoduodenostomy in the rat with obstructive jaundice. J Surg Res 23:321-331, 1977 16. Goeting NLM, Fleming JS, Gallagher P, et al: Alteration in liver blood flow and reticuloendothelial function in progressive cirrhosis in the rat. J Nucl Med 27:1751-1754,1986 17. Katz S, Yang R, Rodefeld MJ, et al: Impaired hepatic bacterial clearance is reversed by surgical relief of obstructive jaundice. J Pediatr Surg 26:401-406,199l 18. Lanser ME, Saba TM: Neutrophil-mediated lung localization of bacteria: A mechanism of pulmonary injury. Surgery 90:473-481,198l
IMPAIRED
CLEARANCE
OF CANDIDA
ALBICANS
907
Discussion S. Lacey (Chapel Hill, NC): In another study that you presented this morning you demonstrated a significant weight loss in the group of animals with CDL. In this study were the animals’ weights comparable? If the sham group did not have the same degree of weight loss, is it really fair to compare the two groups and say that the decreased liver clearance is secondary to the ligation rather than to malnutrition and resultant immunocompromise? A. Pulito (Lexington, KY): How does the clinical picture of TPN-induced cholestasis in the neonate relate to acute total CDL as produced in your experimental animal?
S. Katz (response): The CDL rats failed to grow but did not lose weight. The sham-operated controls were studied a week following operation. At that time there was no significant difference in weight between the experimental groups. TPN-induced cholestasis is a well-established clinical entity. There is some similarity between our model of acute biliary obstruction and TPN cholestasis. In the first 2 weeks following CDL, there was no significant change in RES function. Prolonged jaundice (3 weeks) with continuous deterioration of liver function resulted in phagocytic dysfunction.
