Coexistent cutaneous Aspergillus and cytomegalovirus infection in a liver transplant recipient

Cytomegalovirus induced genital ulcer in human immunodeficiency virus positive patient

Cytomegalovirus (CMV) can cause life-threatening disease in immunocompromised patients, such as those with human immunodeficiency virus. It is a rare but important cause of ulceration in the female genital tract. Although cutaneous manifestations are rare, there are growing reports of CMV infections in genital and perigenital ulcers in immunocompromised individuals. CMV disease of the female genital tract may result in significant morbidity, with fever, pain, bleeding, and superinfection, and it may be associated with the development of pelvic inflammatory disease and cervical intraepithelial neoplasia. There are several options for diagnosis and for safe treatment.

Aspergillus Genus and Its Various Human Superficial and Cutaneous Features

Superficial and cutaneous aspergillosis is a rare fungal disease that is restricted to the outer layers of the skin, nails, and the outer auditory canal, infrequently invading the deeper tissue and viscera, particularly in immunocompromised patients. These mycoses are acquired through two main routes: direct traumatic inoculation or inhalation of airborne fungal spores into paranasal sinuses and lungs. Lesions are classified into three categories: otomycosis, onychomycosis, and cutaneous aspergillosis. Superficial and cutaneous aspergillosis occurs less frequently and therefore remains poorly characterized; it usually involves sites of superficial trauma-namely, at or near intravenous entry catheter site, at the point of traumatic inoculation (orthopaedic inoculation, ear-self-cleaning, schizophrenic ear self-injuries), at surgery incision, and at the site of contact with occlusive dressings, especially in burn patients. Onychomycosis and otomycosis are more seen in immunocompetent patients, while cutaneous aspergillosis is widely described among the immunocompromised individuals. This paper is a review of related literature.

Invasive aspergillosis in liver transplant recipients: epidemiology, clinical characteristics, treatment, and outcomes in 116 cases

Invasive aspergillosis (IA) in liver transplant recipients is associated with grave outcomes. We reviewed 116 individual cases reported in the literature from 1985 to 2013. IA was diagnosed after a median of 25 days after transplantation and involved a single organ in 51% of the cases, whereas in the remaining cases, multiple sites were involved. The most common infecting Aspergillus species were Aspergillus fumigatus (73%), Aspergillus flavus (14%), and Aspergillus terreus (8%). Amphotericin B was the drug most frequently used, and it was followed by voriconazole and itraconazole. Combination regimens were used in 51% of the cases. The overall 1-year cumulative survival probability was 35% [95% confidence interval (CI) = 24.6%-49.6%]. Survival was significantly higher for patients reported from the year 2000 and thereafter (P < 0.001), for those diagnosed with IA more than 30 days after transplantation versus those diagnosed earlier (P = 0.019), and for patients without renal failure (P = 0.020). Additionally, the use of voriconazole was significantly associated with a higher probability of survival (P < 0.001). Cox regression analysis showed that subjects with the involvement of multiple sites had a 2.52 times higher risk of a negative outcome (95% CI = 1.08-5.87) than those with the involvement of a single site. Thus, IA causes life-threatening infections in liver transplant recipients. Predictors associated with poor outcomes may help clinicians to optimize the management of this infection.

Cytomegalovirus and Aspergillus spp. coinfection in organ transplantation: a case report and review of the literature

With the advent of potent immunosuppressive options, acute rejection episodes have decreased at the expense of increased incidence of opportunistic infections in solid organ recipients. In the absence of any preventive therapy, 30–75 % of transplant recipients develop cytomegalovirus (CMV) infection. Candida spp. and Aspergillus spp. account for more than 80 % of invasive fungal infections in solid organ recipients. This co-occurrence of two commonly seen opportunistic infections may end up in fatality. Here, we present a case of concomitant Aspergillus spp. and CMV infection and discuss the relevant literature. A 54-year-old male patient presented with fever, shortness of breath, and chest pain on the 9th posttransplant week after renal transplantation. CMV-DNA by polymerase chain reaction (PCR) was 1,680,000 copies/ml, thus, valganciclovir dose was increased. There were inspiratory crackles at both lung bases, and chest computed tomography (CT) revealed multiple fungal balls throughout the right lung. Galactomannan antigen was positive, and voriconazole and other antimicrobials were subsequently added to the treatment. At the end of the therapy, on control CT, pneumonic consolidation had disappeared, sputum cultures didn’t show Aspergillus spp., and CMV-DNA reduced to 700 copies/ml. The patient showed a favorable clinical response to combined treatment; fever, dyspnea, and pleuritic chest pain disappeared. Both CMV disease and aspergillosis may present as pulmonary disease; thus, the characterization of one may not preclude the search for the other and the timely initiation of treatment is of paramount importance for good outcomes.

The impact of the host on fungal infections

Outcomes of fungal infections in immunocompromised individuals depend on a complex interplay between host and pathogen factors, as well as treatment modalities. Problems occur when host responses to an infection are either too weak to effectively help eradicate the pathogen, or when they become too strong and are associated with host damage rather than protection. Immune reconstitution syndrome (IRS) can be generally defined as a restoration of host immunity in a previously immunosuppressed patient that becomes dysregulated and overly robust, resulting in host damage and sometimes death. IRS associated with opportunistic mycoses presents as new or worsening clinical symptoms or radiographic signs consistent with an inflammatory process that occur during receipt of an appropriate antifungal, and that cannot be explained by a newly acquired infection. Because there are currently no established tests or biomarkers for IRS, it can be difficult to distinguish from progression of the original infection, although culture and biomarkers for the fungal pathogen or infection are typically negative during diagnostic workup. IRS was originally characterized in human immunodeficiency virus-infected patients receiving antiretroviral therapy, but has subsequently been described in solid-organ transplant recipients, neutropenic patients, women in the postpartum period, and recipients of tumor necrosis factor-α inhibitor therapy. In each of these cases, recovery of the host's immunity during treatment of an initial infection results in a powerful proinflammatory environment that overshoots and leads to host damage. Optimal management of IRS has not been established at present, but often involves treatment with a corticosteroid or other anti-inflammatory compounds. This article uses a number of patient cases to explore the intricacies of diagnosing and managing a patient with IRS, as well as the other extreme, namely patients who are so immunocompromised without immune recovery that they essentially become breeding grounds for a wide range of opportunistic pathogens, often simultaneously.

Aspergillus flavus: an emerging non-fumigatus Aspergillus species of significance

Invasive aspergillosis is rare in immunocompetent people but contributes to significant morbidity and mortality in immunosuppressed patients. The majority (approximately 80%) of invasive Aspergillus infections is caused by Aspergillus fumigatus. The second most frequent (approximately 15-20%) pathogenic species is Aspergillus flavus and to a lesser extent, Aspergillus niger and Aspergillus terreus. Aspergillus flavus has emerged as a predominant pathogen in patients with fungal sinusitis and fungal keratitis in several institutions worldwide. To date, there has not been any publication exclusively reviewing the topic of A. flavus in the literature. This article reviews the microbiology, toxigenicity and epidemiology of A. flavus as well as describes the clinical characteristics, diagnosis and management of infections caused by this organism.

Fatal outcome of disseminated invasive aspergillosis in kidney allograft recipients

Fungal infections in solid organ transplant recipients are of concern due to the related high mortality and morbidity. Aspergillus species are one of the major opportunistic fungal pathogens causing invasive pulmonary infections which rarely involve extrapulmonary organs. The occurrence varies by type of transplantation, with aspergillosis more frequently associated with heart, liver and lung transplantation cases than those involving kidney recipients. Several risk factors have been proposed, with cases occurring early and late after the transplantation. Although pulmonary involvement is the main presentation, invasive extrapulmonary aspergillosis can on rare occasions be observed and is associated with poor prognosis. Herein, we report two cases that presented with extrapulmonary invasive aspergillosis, i.e., one presented with cerebral abscess and the second with soft tissue abscess in the right posterior thigh. While the cerebral abscess was not surgically treated, the soft tissue abscess was surgically drained. When the primary focus was investigated, pulmonary nodulars were found in both cases. Both patients were treated with long-term amphotericin B; however, one patient was lost with functioning graft and the kidney of the second patient failed due to decreased immunosuppression and he died while on maintenance hemodialysis. Invasive extrapulmonary presentation of aspergillosis rarely occurs in kidney transplant recipients and is associated with a high mortality rate.

Fatal case of Aspergillus coinfection in a renal transplant recipient suffering from cytomegalovirus pneumonitis (Case Report)

Cytomegalovirus (CMV) disease is common in postrenal transplant recipients, and may predispose the patients to secondary bacterial or fungal infections. However, simultaneous coinfection is rare and often makes diagnosis difficult. We report a case of CMV pneumonitis in a renal transplant recipient presenting with elevated CMV pp65 antigen level and abnormal chest radiograph. Despite potent and broad-spectrum antimicrobial therapy, his condition deteriorated rapidly - he soon went into respiratory failure, septic shock and died several days later. Transbronchial biopsy and bronchoalveolar lavage obtained before the patient's death showed evidence of invasive pulmonary aspergillosis with concomitant CMV pneumonitis. High index of suspicion and early and empirical initiation of antifungal therapy may be necessary for successful management of fulminant pneumonia in solid organ transplant recipients.

Nontumoral dermatologic problems after liver transplantation

The skin, easily accessible for medical examination, is affected in many ways by liver transplantation. Mucocutaneous manifestations of advanced liver disease and dermatologic conditions associated with specific hepatic diagnoses generally improve after liver transplantation. Vasculitic lesions due to cryoglobulinemia associated with hepatitis C, and photosensitivity due to porphyria are occasional exceptions. Dermatologic diseases complicating the posttransplantation course can be challenging. Their presentation is sometimes unusual and their course severe. Infections with rare organisms alone or in combination may occur. Our intent is to provide an overview of the current knowledge regarding nontumoral dermatologic problems associated with liver transplantation by summarizing the available information from all documented case reports.

Cutaneous infection caused byAlternariain patients receiving tacrolimus

Tacrolimus, an immunosuppressant used in organ transplant surgery, is inhibitory to some medically important fungi but also may obstruct azole monotherapy in the immunocompromised patient. We observed a case of cutaneous phaeohyphomycosis caused by Alternaria alternata in a liver transplant recipient who had been under tacrolimus immunosuppression for 6 months post-transplantation. At the onset of the infection, the patient presented with an increased whole-blood tacrolimus level. After a simple surgical excision the patient was discharged from the hospital without antifungal treatment but with an adjusted tacrolimus dosage. Literature review on fungal infections in patients receiving tacrolimus suggested these patients experience cutaneous and deep mould infections that are more frequent, severe and therapy-refractory than those seen in patients with other types of immunosuppression.