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Khosla A, Singhal S, Jotwani P, Kleyman R. Cerebral Toxoplasmosis As the Initial Presentation of HIV: A Case Series. Cureus 2022; 14:e23359. [PMID: 35475054 PMCID: PMC9018902 DOI: 10.7759/cureus.23359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2022] [Indexed: 11/21/2022] Open
Abstract
The HIV epidemic afflicts millions across the globe, and Sub-Saharan countries bear a disproportionately high burden. Cerebral toxoplasmosis is commonly seen as the disease progresses but is rarely ever reported as the initial manifestation of HIV. The clinical presentation, co-existing risk factors, and outcomes remain underreported. The objective of this article is to report cerebral toxoplasmosis as the initial manifestation of HIV. This is a consecutive series of three patients that presented to a community hospital in Pennsylvania, United States, with a variety of neuropsychiatric symptoms and were found to have cerebral toxoplasmosis. The findings are compared with existing literature on cerebral toxoplasmosis as the initial manifestation of HIV. Cerebral toxoplasmosis as the initial manifestation of HIV is a rarely reported phenomenon. Hyponatremia may be linked with this disease-complex, although further studies are warranted to establish a causal relationship. Co-infection with hepatitis viruses is also a common finding in these patients.
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Toxoplasma gondii Monitoring in Liver Transplantation Patients: A Single Center Cross-Sectional Study in an Italian Hospital. Pathogens 2020; 9:pathogens9050354. [PMID: 32397187 PMCID: PMC7281584 DOI: 10.3390/pathogens9050354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 11/16/2022] Open
Abstract
Toxoplasma gondii (TG) is one of the most widespread intracellular parasites in the world, despite the slight declining trend in industrialized countries. Whilst the infection is often asymptomatic in immunocompetent hosts, in immunocompromised patients such as organ transplant recipients it can have important clinical sequels with even fatal consequences. We retrospectively reviewed 568 primary liver transplants (LT) from deceased donors from 2012 to 2017. Data were analyzed adjusting for year, gender, and age. The study objective was to assess the incidence of post-transplant TG infection and adherence to international guidelines for primary chemoprophylaxis. Prior to transplantation, 42.4% of recipients tested seronegative and 56.5% seropositive, while 36.6% of donors were seropositive and 40.4% showed undetermined serology. Anti-TG antibody titer was higher in patients born abroad (71.4%) versus Italy (54.8%). Among recipients at high risk of post-transplant TG infection, 82.7% of them received chemoprophylaxis, while in 17.3% of cases no prophylaxis was administered. At a mean (SD) follow-up of 21.2 (12.4) months no case of TG infection has been observed. Despite the low rate of adherence to recommendations, prophylaxis of high-risk LT recipients provides control of post-transplant TG infection risk. Review of current guidelines is warranted for low-risk populations.
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Abstract
AbstractInfections by the protozoan parasite Toxoplasma gondii are widely prevalent in humans and animals in Turkey but little is known of the burden of their clinical toxoplasmosis. Many early papers on toxoplasmosis in Turkey were published in Turkish and often not available widely. Here, we review prevalence, clinical spectrum, epidemiology and diagnosis of T. gondii in humans and animals in Turkey. This knowledge should be useful to biologists, public health workers, veterinarians and physicians. Although one-third of the human population in Turkey is seropositive, the rate of congenital toxoplasmosis is unknown and no information is available in children 12 years old or younger. One large outbreak of acute toxoplasmosis has been reported in 14–18-year old school children in Turkey. An alarming rate (36%) of T. gondii tissue cysts were reported in tissues of sheep and water buffalo meats destined for human consumption; these reports require verification. Genetically, T. gondii strains from domestic cats and wild birds in Turkey were generally classical type II and III, like those prevalent in Europe. A separate genotype, Type 1 Africa, was isolated from two congenitally infected children and a domestic cat in Turkey.
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Toxoplasmosis in the non-orthotopic heart transplant recipient population, how common is it? Any indication for prophylaxis? Curr Opin Organ Transplant 2019; 23:407-416. [PMID: 29878911 DOI: 10.1097/mot.0000000000000550] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE OF REVIEW Unlike in orthotopic heart transplant (OHT) setting where toxoplasma prophylaxis is a standard practice in pretransplant toxoplasma seronegative recipients who have received donor hearts from seropositive donors (D+/R-), there is no consensus regarding prophylaxis in non-OHT recipients. RECENT FINDINGS The incidence of toxoplasma disease in non-OHT recipients is less than 1% but its true burden is underestimated. Among 31 cases of toxoplasma disease reported from 2004 through 2017, renal and liver transplant recipients comprised of 90% of cases. A total of 94% of 18 recipients with known pretransplant serology were seronegative recipients (mostly D+/R-). Out of 16 recipients with adequate information, 10 (63%) and five (31%) were deemed to be donor derived and nondonor-derived primary toxoplasmosis respectively. Tissue invasive reactivation was uncommon. Almost all cases were described in patients not on prophylaxis at the time of presentation. Universal screening of donor/recipient toxoplasma serology for risk stratification is beneficial as illustrated by reports of fatal cases of toxoplasmosis due to unavailability of positive donor serology results. SUMMARY Toxoplasma disease in non-OHT predominantly occurs in pretransplant seronegative recipients- mostly in D+/R- group and is rare in seropositive recipients. Posttransplant prophylaxis should be targeted against the high-risk D+/R- group and should be considered in seropositive recipients in whom unusually high immunosuppression is implemented. Toxoplasma serologies and PCR should be used in combination for the diagnosis of toxoplasmosis in non-OHT patients.
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Fabiani S, Fortunato S, Bruschi F. Solid Organ Transplant and Parasitic Diseases: A Review of the Clinical Cases in the Last Two Decades. Pathogens 2018; 7:pathogens7030065. [PMID: 30065220 PMCID: PMC6160964 DOI: 10.3390/pathogens7030065] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 07/17/2018] [Accepted: 07/18/2018] [Indexed: 12/18/2022] Open
Abstract
The aim of this study was to evaluate the occurrence of parasitic infections in solid organ transplant (SOT) recipients. We conducted a systematic review of literature records on post-transplant parasitic infections, published from 1996 to 2016 and available on PubMed database, focusing only on parasitic infections acquired after SOT. The methods and findings of the present review have been presented based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. From data published in the literature, the real burden of parasitic infections among SOT recipients cannot really be estimated. Nevertheless, publications on the matter are on the increase, probably due to more than one reason: (i) the increasing number of patients transplanted and then treated with immunosuppressive agents; (ii) the “population shift” resulting from immigration and travels to endemic areas, and (iii) the increased attention directed to diagnosis/notification/publication of cases. Considering parasitic infections as emerging and potentially serious in their evolution, additional strategies for the prevention, careful screening and follow-up, with a high level of awareness, identification, and pre-emptive therapy are needed in transplant recipients.
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Affiliation(s)
- Silvia Fabiani
- Infectious Disease Department, Azienda Ospedaliera Pisana, 56124 Pisa, Italy.
- School of Infectious Diseases, Università di Pisa, 56124 Pisa, Italy.
| | - Simona Fortunato
- School of Infectious Diseases, Università di Pisa, 56124 Pisa, Italy.
| | - Fabrizio Bruschi
- School of Infectious Diseases, Università di Pisa, 56124 Pisa, Italy.
- Department of Translational Research, N.T.M.S., Università di Pisa, 56124 Pisa, Italy.
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Autier B, Dion S, Robert-Gangneux F. The liver as an organ at risk for Toxoplasma transmission during transplantation: myth or reality? J Clin Pathol 2018. [PMID: 29535213 DOI: 10.1136/jclinpath-2018-205066] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
AIM Toxoplasmosis following liver transplant with donor-recipient mismatch is rare, but is often life-threatening. However, there are no data on the frequency of cyst carriage in the liver, nor consensual chemoprophylaxis guidelines. This study aimed at describing frequency and localisation of Toxoplasma cysts in the liver in a mouse model of chronic infection to predict the risk in liver transplantation. METHODS Heart, brain and liver lobes of 21 mice chronically infected with Toxoplasma were collected for DNA extraction and amplification of Toxoplasma gondii rep529 sequence by real-time PCR. RESULTS Parasite DNA was detected in the liver of 19/21 mice (90.5%), with no preferential anatomical localisation, but with higher parasite loads in the papillary process. Parasite loads in the liver were far lower than in brain and heart. The number of infected lobes was inversely correlated to the total liver weight, but was independent of the brain parasite load and of the parasite strain. CONCLUSIONS The liver is a frequent site of cyst carriage, confirming that transplantation of an organ from a seropositive donor to seronegative recipient is at high risk for acquired toxoplasmosis. Systematic serological screening prior to transplantation and chemoprophylaxis in patients at risk are fully justified.
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Affiliation(s)
- Brice Autier
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Sarah Dion
- Institut de recherche en santé, environnement et travail, Inserm U0185, Rennes, France.,Université Rennes 1, Rennes, France
| | - Florence Robert-Gangneux
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire de Rennes, Rennes, France.,Institut de recherche en santé, environnement et travail, Inserm U0185, Rennes, France.,Université Rennes 1, Rennes, France
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Galván-Ramírez MDLL, Sánchez-Orozco LV, Gutiérrez-Maldonado AF, Rodriguez Pérez LR. Does Toxoplasma gondii infection impact liver transplantation outcomes? A systematic review. J Med Microbiol 2018; 67:499-506. [PMID: 29458555 DOI: 10.1099/jmm.0.000694] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Approximately one-third of the world's population has Toxoplasma gondii infection, and one of the main routes of transmission is organ transplantation. The aim of this study was to evaluate the impact of Toxoplasma infection on liver transplantation patients. METHODOLOGY We searched PubMed, Lilacs, Medline, Science direct, Scielo, Ebsco, Springer, Wiley, Ovid and Google Scholar for reports published up to June 2017, and a systematic review was performed. RESULTS Twenty cases were analysed before and after liver transplantation. Primary and reactivated infections were investigated. Before transplantation, positive IgG antibodies were the predominant serological markers in donors and recipients: 40 % (D+/R-), 20 % (D+/R+) and 20 % (D-/R+). IgM was present in only 5 % of the donors (D+/R-). In four cases, the serological markers were not specified or were negative (D?/R? or D?/R-). After transplantation, IgM anti-Toxoplasma antibodies were found in 30 % of the recipients, and in 67 % of the seronegative recipients the presence of Toxoplasma DNA or tachyzoites was reported, suggesting a primary infection. Clinical symptoms were meningitis, massive cerebral oedema, encephalitis and seizures. Treatment was administered in 70 % of the patients, and 40 % died after presenting symptoms associated with Toxoplasma infection. CONCLUSIONS Although we review Toxoplasma infection and liver transplantation cases, problems associated with the parasite may be greater than identified. Hence, follow-up studies on Toxoplasma infection in liver transplantation patients are recommended.
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Affiliation(s)
- Maria de la Luz Galván-Ramírez
- Department of Physiology, Neurophysiology Laboratory, Health Sciences University Center, University of Guadalajara, Guadalajara, Jalisco, Mexico
| | - Laura V Sánchez-Orozco
- Department of Molecular Biology and Genomics, Health Sciences University Center, University of Guadalajara, Guadalajara, Jalisco, Mexico
| | - Adrián Fernando Gutiérrez-Maldonado
- Department of Physiology, Neurophysiology Laboratory, Health Sciences University Center, University of Guadalajara, Guadalajara, Jalisco, Mexico
| | - Laura Roció Rodriguez Pérez
- Department of Physiology, Neurophysiology Laboratory, Health Sciences University Center, University of Guadalajara, Guadalajara, Jalisco, Mexico
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Webb GJ, Shah H, David MD, Tiew S, Beare N, Hirschfield GM. Post-prophylaxis Toxoplasma chorioretinitis following donor-recipient mismatched liver transplantation. Transpl Infect Dis 2017; 18:805-808. [PMID: 27500398 PMCID: PMC5053268 DOI: 10.1111/tid.12589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 04/19/2016] [Accepted: 06/06/2016] [Indexed: 11/28/2022]
Abstract
Toxoplasmosis may be transferred by organ transplantation. The most common clinical presentation is with multisystem disease, although isolated ocular toxoplasmosis has been described. Many centers have suggested that universal use of co-trimoxazole prophylaxis obviates the need for specific Toxoplasma testing. We report a case of donor-acquired ocular toxoplasmosis after liver transplantation despite co-trimoxazole prophylaxis. The diagnosis was confirmed by Toxoplasma polymerase chain reaction assay in conjunction with seroconversion. The fact that the infection was donor acquired was confirmed by serological mismatch and the absence of sporozoite-specific antigen antibody in the recipient.
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Affiliation(s)
- G J Webb
- National Institute of Health Research Birmingham Liver Biomedical Research Unit, Birmingham, UK
| | - H Shah
- National Institute of Health Research Birmingham Liver Biomedical Research Unit, Birmingham, UK
| | - M D David
- Clinical Microbiology, Queen Elizabeth Hospital, Birmingham, UK
| | - S Tiew
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - N Beare
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - G M Hirschfield
- National Institute of Health Research Birmingham Liver Biomedical Research Unit, Birmingham, UK.
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Wang ZD, Liu HH, Ma ZX, Ma HY, Li ZY, Yang ZB, Zhu XQ, Xu B, Wei F, Liu Q. Toxoplasma gondii Infection in Immunocompromised Patients: A Systematic Review and Meta-Analysis. Front Microbiol 2017; 8:389. [PMID: 28337191 PMCID: PMC5343064 DOI: 10.3389/fmicb.2017.00389] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 02/24/2017] [Indexed: 01/01/2023] Open
Abstract
Toxoplasma gondii has been suggested as an important opportunistic pathogen in immunocompromised patients. We conducted a global meta-analysis to assess the prevalence and odds ratios (ORs) of T. gondii infection in immunocompromised individuals. Electronic databases were reviewed for T. gondii infection in HIV/AIDS patients, cancer patients, and transplant recipients, and meta-analyses were conducted to calculate overall estimated prevalence and ORs using random or fixed-effects models. Totally, 72 eligible studies were included. The estimated pooled prevalence of T. gondii infection in immunocompromised patients and the control was 35.9 and 24.7% (p < 0.001), with an OR of 2.24, i.e., 42.1 and 32.0% for HIV/AIDS patients and the control (p < 0.05), 26.0 and 12.1% for cancer patients and the control (p < 0.001), and 42.1 and 34.5% for transplant recipients and the control (p > 0.05), whose estimated pooled ORs were 1.92 (95% CI, 1.44-2.55), 2.89 (95% CI, 2.36-3.55), and 1.51 (95% CI, 1.16-1.95), respectively. This study is the first to demonstrate that the immunocompromised patients are associated with higher odds of T. gondii infection, and appropriate prevention and control measures are highly recommended for these susceptible populations.
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Affiliation(s)
- Ze-Dong Wang
- College of Life Science, Jilin Agricultural UniversityChangchun, China; State Key Laboratory of Veterinary Etiological Biology, Key Laboratory of Veterinary Parasitology of Gansu Province, Lanzhou Veterinary Research Institute, Chinese Academy of Agricultural SciencesLanzhou, China; Key Laboratory of Jilin Province for Zoonosis Prevention and Control, Military Veterinary Institute, Academy of Military Medical SciencesChangchun, China
| | - Huan-Huan Liu
- Key Laboratory of Jilin Province for Zoonosis Prevention and Control, Military Veterinary Institute, Academy of Military Medical Sciences Changchun, China
| | - Zhan-Xi Ma
- Department of Emergency Medicine, Inner Mongolia General Forestry Hospital Yakeshi, China
| | - Hong-Yu Ma
- Key Laboratory of Jilin Province for Zoonosis Prevention and Control, Military Veterinary Institute, Academy of Military Medical Sciences Changchun, China
| | - Zhong-Yu Li
- Key Laboratory of Jilin Province for Zoonosis Prevention and Control, Military Veterinary Institute, Academy of Military Medical Sciences Changchun, China
| | - Zhi-Bin Yang
- Medical Library of the Chinese people's Liberation Army Beijing, China
| | - Xing-Quan Zhu
- State Key Laboratory of Veterinary Etiological Biology, Key Laboratory of Veterinary Parasitology of Gansu Province, Lanzhou Veterinary Research Institute, Chinese Academy of Agricultural Sciences Lanzhou, China
| | - Bin Xu
- Center for Prevention and Control of Animal Diseases of Banan District in Chongqing Chongqing, China
| | - Feng Wei
- College of Life Science, Jilin Agricultural University Changchun, China
| | - Quan Liu
- Key Laboratory of Jilin Province for Zoonosis Prevention and Control, Military Veterinary Institute, Academy of Military Medical SciencesChangchun, China; Key Laboratory of Zoonoses, Ministry of EducationChangchun, China
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Aksoy U, Marangi M, Papini R, Ozkoc S, Bayram Delibas S, Giangaspero A. Detection of Toxoplasma gondii and Cyclospora cayetanensis in Mytilus galloprovincialis from Izmir Province coast (Turkey) by Real Time PCR/High-Resolution Melting analysis (HRM). Food Microbiol 2014; 44:128-35. [DOI: 10.1016/j.fm.2014.05.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 04/04/2014] [Accepted: 05/23/2014] [Indexed: 01/03/2023]
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Murat JB, Fricker Hidalgo H, Brenier-Pinchart MP, Pelloux H. Human toxoplasmosis: which biological diagnostic tests are best suited to which clinical situations? Expert Rev Anti Infect Ther 2014; 11:943-56. [DOI: 10.1586/14787210.2013.825441] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Döşkaya M, Caner A, Ajzenberg D, Değirmenci A, Dardé ML, Can H, Erdoğan DD, Korkmaz M, Uner A, Güngör C, Altıntaş K, Gürüz Y. Isolation of Toxoplasma gondii strains similar to Africa 1 genotype in Turkey. Parasitol Int 2013; 62:471-4. [PMID: 23811201 DOI: 10.1016/j.parint.2013.06.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 05/22/2013] [Accepted: 06/21/2013] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Toxoplasma gondii is a protozoon parasite that has a worldwide dissemination. It can cause serious clinical problems such as congenital toxoplasmosis, retinochoroiditis, and encephalitis. Currently, T. gondii genotypes are being associated with these clinical presentations which may help clinicians design their treatment strategy. CASE REPORTS Two T. gondii strains named Ankara and Ege-1 were isolated from newborns with congenital toxoplasmosis in Central and Western Anatolia, respectively. Ankara and Ege-1 strains were isolated from the cerebrospinal fluid of newborns. According to microsatellite analysis, Ankara and Ege-1 strains were sorted as Africa 1 genotype. CONCLUSION T. gondii strains isolated in Turkey were first time genotyped in this study. Africa 1 genotype has previously been isolated in immunosuppressed patients originating from sub-Saharan Africa. The reason of detecting a strain mainly detected in Africa can be associated with Turkey's specific geographical location. Turkey is like a bridge between Asia, Europe and Africa. Historically, Anatolia was on the Silk Road and other trading routes that ended in Europe. Thus, detecting Africa 1 strain in Anatolia can be anticipated. Consequently, strains detected mainly in Europe and Asia may also be detected in Anatolia and vice versa. Therefore, further studies are required to isolate more strains from Turkey.
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Affiliation(s)
- Mert Döşkaya
- Department of Parasitology, Ege University Medical School, Bornova/İzmir 35100, Turkey.
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Abstract
PURPOSE OF REVIEW Hematopoietic stem cell as well as solid-organ transplantation is being carried out with increasing frequency throughout the world. Lower respiratory tract infections (LRTIs) remain a common life-threatening complication faced by the transplant recipients. The purpose of this review is to provide up-to-date information on pulmonary infections among the transplant recipients, especially emphasizing the endemicity of microorganisms, epidemiology, work-up of infections, and principles of their management. RECENT FINDINGS A lower respiratory tract infection such as pneumonia is the most frequent of all the infections and is associated with high morbidity and mortality. Factors increasing the risk of pulmonary infections include surgical techniques, immune status, chemoradiotherapy, alloimmune mechanisms between the host and the graft, and the environment. A high degree of suspicion, computed tomography (CT) scan of the chest, and flexible bronchoscopy are required in most to establish the diagnosis. SUMMARY Proper management of LRTI in transplant recipients requires a high degree of suspicion, thorough knowledge of the epidemiology and endemicity of the suspected organisms, CT scan of the chest, and expertise at bronchoscopy. Utmost teamwork among transplant physicians, infectious disease specialist, and bronchoscopist is essential.
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Abstract
PURPOSE OF REVIEW To provide an updated perspective of the most common parasitic infections occurring in solid-organ transplant (SOT) recipients. RECENT FINDINGS Parasitic infections are an emerging problem in SOT programs and represent a diagnostic and therapeutic challenge. Transplantation in endemic areas - including medical tourism, international travel and migration - justify the necessity of considering parasitic infections in the differential diagnosis of posttransplant complications. Molecular techniques, such as PCR, may improve the diagnostic accuracy and help during the follow-up. SUMMARY Parasitic infections are an uncommon but potentially severe complication in SOT recipients. An increase of donors emigrated from tropical areas and more posttransplant patients traveling to endemic areas have led to a rise in parasitic infections reported among SOT recipients. Transplant physicians should get familiar with parasitic infections and promote adherence to preventive measures in SOT recipients.
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Abstract
Parasitic infections are an uncommon but potentially severe complication in solid organ transplant (SOT) recipients. An increase in donors who have emigrated from tropical areas and more transplant recipients traveling to endemic areas have led to a rise in parasitic infections reported among SOT recipients. Clinicians should include these infections in their differential diagnosis and promote adherence to preventive measures in SOT recipients.
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