Aspergillosis in 25 renal transplant patients. Epidemiology, clinical presentation, diagnosis, and management

Risk factors for the development of invasive aspergillosis after kidney transplantation: Systematic review and meta-analysis

To investigate risk factors for invasive aspergillosis (IA) after kidney transplantation (KT), we conducted a systematic search in PubMed and EMBASE to identify studies published until June 2020. We included case-control or cohort design studies comprising KT recipients with a diagnosis of IA, defined according to the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group criteria, and assessed risk factors for the development of IA. Random-effect models meta-analysis served to pool data. We identified eleven case-control studies (319 IA cases and 835 controls). There was an increased risk of IA among recipients with underlying chronic lung diseases (odds ratio [OR] = 7.26; 95% confidence interval [CI] = 1.05-50.06) and among those with diabetic nephropathy (OR = 1.65; 95% CI = 1.10-2.48). Requiring posttransplant hemodialysis (OR = 3.69; 95% CI = 2.13-6.37) or surgical reintervention (OR = 6.28; 95% CI = 1.67-23.66) were also associated with an increased risk. Moreover, a positive link was identified between IA and posttransplant bacterial infection (OR = 7.51; 95% CI = 4.37-12.91), respiratory tract viral infection (OR = 7.75; 95% CI = 1.60-37.57), cytomegalovirus infection or disease (OR = 2.67; 95% CI = 1.12-6.32), and acute graft rejection (OR = 3.01; 95% CI = 1.78-5.09). In contrast, receiving a kidney from a living donor was associated with a reduced risk (OR = 0.65; 95% CI = 0.46-0.93). KT recipients that accumulate several of these conditions should be closely monitored and a low threshold of suspicion for IA should be maintained. Future studies should explore the benefit of mold-active prophylaxis to this subgroup of KT recipients at highest risk.

Baseline predictors influencing the prognosis of invasive aspergillosis in adults

Invasive aspergillosis (IA) is a serious hazard to haematological and critical care patients. Impactful risk factors for developing IA have been characterised; however, systematic analysis of baseline prognostic factors for treatment course of IA is missing. To understand prognostic variables, we analysed original articles identifying baseline factors that predict treatment outcome in patients with IA. PubMed database was searched for publications since database inception until May 2018. Inclusion criteria were published baseline prognostic factors present at the diagnosis of IA. In total, 58 studies from 267 centres reported 7320 patients with IA and 40 different predictors. Unfavourable predictors in medical history were kidney (7.4%, 10/136) and liver failure (3.7%, 5/136), ICU admission (3.7%, 5/136) and uncontrolled underlying disease (3.7%, 5/136). Regarding state of immunosuppression, negative outcome predictors were prolonged neutropenia (12.5%, 17/136), corticosteroid treatment (8.1%, 11/136) and graft-vs-host disease (3.7%, 5/136). On the pathogen side, relevant predictors were galactomannan positivity (8.1%, 11/136), Aspergillus terreus infection (2.2%, 3/136) and lack of amphotericin B susceptibility (1.5%, 2/136). IA-specific predictors were disseminated disease (5.1%, 7/136) and CNS involvement (2.9%, 4/136). Imaging results associated with negative outcome were multiple consolidations (2.9%, 4/136), bipulmonary lesions (2.2%, 3/136) and pleural effusion (2.2%, 3/136). At diagnosis of IA, most frequently identified predictors of outcome were neutropenia, corticosteroid use, elevated galactomannan, renal failure and disseminated disease. The predictors may be used to identify patients at high risk for treatment failure and to stratify neglected patient groups for clinical trials.

Invasive Aspergillosis in solid-organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These updated AST-IDCOP guidelines provide information on epidemiology, diagnosis, and management of Aspergillus after organ transplantation. Aspergillus is the most common invasive mold infection in solid-organ transplant (SOT) recipients, and it is the most common invasive fungal infection among lung transplant recipients. Time from transplant to diagnosis of invasive aspergillosis (IA) is variable, but most cases present within the first year post-transplant, with shortest time to onset among liver and heart transplant recipients. The overall 12-week mortality of IA in SOT exceeds 20%; prognosis is worse among those with central nervous system involvement or disseminated disease. Bronchoalveolar lavage galactomannan is preferred for the diagnosis of IA in lung and non-lung transplant recipients, in combination with other diagnostic modalities (eg, chest CT scan, culture). Voriconazole remains the drug of choice to treat IA, with isavuconazole and lipid formulations of amphotericin B regarded as alternative agents. The role of combination antifungals for primary therapy of IA remains controversial. Either universal prophylaxis or preemptive therapy is recommended in lung transplant recipients, whereas targeted prophylaxis is favored in liver and heart transplant recipients. In these guidelines, we also discuss newer antifungals and diagnostic tests, antifungal susceptibility testing, and special patient populations.

Late-Onset Allograft Aspergillosis in an HIV-Positive Renal Transplant Recipient: A Case Report

Aspergillus infection of the allograft in renal transplant patients is rare and associated with a high mortality. We report a case of a 21-year-old, human immunodeficiency virus-positive, deceased-donor kidney recipient who presented 1 year after transplant with oliguric kidney injury. A nuclear medicine renal scan revealed absence of flow to the transplanted kidney, and a urine fungal culture was positive for Aspergillus flavus. The diagnosis was confirmed with the presence of fungal hyphae along with thrombosis in the vascular structures in renal allograft pathology. We found no evidence of disseminated aspergillosis or involvement of any other organ in the patient. To our knowledge, this case is the first reported in the literature of late-onset non-disseminated renal-limited aspergillosis in a human immunodeficiency virus-positive renal transplant patient.

Causes of Hemoptysis in Renal Transplant Patients

OBJECTIVES

Hemoptysis is a symptom that can be caused by airway disease, pulmonary parenchymal disease, or pulmonary vascular disease, or it can be idiopathic. Infection is the most common cause of hemoptysis, accounting for 60% to 70% of cases. Hemoptysis is also an initial symptom of diffuse alveolar hemorrhage syndrome, although it may be absent at presentation in one-third of patients. Diffuse alveolar hemorrhage is characterized by disruption of the alveolar-capillary basement membranes because of either injury or inflammation of the arterioles, venules, or capillaries, resulting in bleeding in alveolar spaces. To date, no study in the literature has investigated the cause of hemoptysis in renal transplant patients. In this retrospective study, we aimed to investigate the causes of hemoptysis in renal recipients.

MATERIALS AND METHODS

The data included in this study were obtained from 352 renal transplant patients who were consulted by the pulmonology department regarding hemoptysis between 2011 and 2017 at Baskent University. Patient medical records were reviewed for demographic, clinical, radiographic, bronchoscopic features, and microbiology data. Immunosuppressive drugs and clinical outcome data were also noted.

RESULTS

This study included 352 renal transplant patients (139 male patients with mean age of 34.9 ± 7 years and 113 female patients with mean age of 31.1 ± 5 years). Hemoptysis was detected in 17 patients (4.8%),with 3 (0.85%) having massive hemoptysis as a result of diffuse alveolar hemorrhage syndrome. Fourteen of our patient group (4%) had pneumonia, and Aspergillus species was detected in 5 patients (1.4%). The only reason for diffuse alveolar hemorrhage was immunosuppressive agents, including sirolimus and mycophenolate mofetil.

CONCLUSIONS

Hemoptysis is an important respiratory symptom in renal transplant patients. Although community- or hospital-acquired pneumonia may result in hemoptysis, drug-induced diffuse alveolar hemorrhage and Aspergillus infection should be considered for causes in renal transplant patients.

Aspergillus Pericarditis with Tamponade in a Renal Transplant Patient

Aspergillus pericarditis is a rare and life-threatening infection in immunosuppressed patients. It has nonspecific clinical manifestations that often mimic other disease entities especially in patients who have extensive comorbidities. Diagnosis is oftentimes delayed and rarely done antemortem. A high degree of suspicion in immunocompromised patients is necessary for evaluation and timely diagnosis. This is a case of Aspergillus pericarditis with cardiac tamponade in a renal transplant patient with liver cirrhosis. Two months after transplant, he developed decompensation of his cirrhosis from hepatitis C, acute cellular rejection, and Kluyvera bacteremia, followed by vancomycin-resistant Enterococcus faecium (VRE) bacteremia. Four months after transplant, the patient presented with lethargy and fluid overload. He subsequently developed shock and ventilator-dependent respiratory failure. An echocardiogram showed pericardial effusion with cardiac tamponade. He had emergent pericardiocentesis that showed purulent drainage. He was started on broad-spectrum antibiotics. Amphotericin B was initiated when the pericardial fluid grew mold that was later identified as Aspergillus fumigatus. The patient quickly decompensated and expired.

Renal Allograft Aspergillus Infection Presenting With Obstructive Uropathy: A Case Report

BACKGROUND

Isolated renal allograft aspergillosis is rare and usually presents with fever and decreased glomerular filtration rate. Presentation with obstructive uropathy caused by aspergillus fungal balls is much less common. We report a young male patient who presented with obstructive uropathy secondary to isolated renal allograft aspergillus infection 6 weeks after transplant. He was treated with nephrectomy and antifungal medications.

CASE PRESENTATION

A 29-year-old Saudi male patient had a recent living non-related kidney transplantation in Pakistan. Early Post-transplant course was complicated by acute cellular rejection (Banff Class IB) which was managed successfully with pulse steroid and anti-thymocyte globulin. The patient presented again to our emergency room on fortieth day post-transplant with a complaint of decreased urine output and passing white particles in his urine. This presentation was three Three weeks after treatment for cellular rejection, the urine fungal culture showed growth of Aspergillus fumigatus, and ultrasound imaging of the allograft kidney revealed mild to moderate hydronephrosis with echogenic materials within the renal pelvis. Biopsy of the transplanted kidney showed severe necrotizing granulomatous inflammation and fungal elements consistent with aspergillus species. The patient was given voriconazole as an antifungal agent and was weaned from immunosuppressive medication. The patient eventually required intermittent hemodialysis and underwent surgical allograft nephrectomy.

CONCLUSION

Suboptimal environmental and infection prevention and control precautions can explain this type of infection. It is important for clinicians to have a high index of suspicion and to investigate for fungal infection as a rare cause of obstructive uropathy in high-risk patients.

Neutrophil Interactions Stimulate Evasive Hyphal Branching by Aspergillus fumigatus

Invasive aspergillosis (IA), primarily caused by Aspergillus fumigatus, is an opportunistic fungal infection predominantly affecting immunocompromised and neutropenic patients that is difficult to treat and results in high mortality. Investigations of neutrophil-hypha interaction in vitro and in animal models of IA are limited by lack of temporal and spatial control over interactions. This study presents a new approach for studying neutrophil-hypha interaction at single cell resolution over time, which revealed an evasive fungal behavior triggered by interaction with neutrophils: Interacting hyphae performed de novo tip formation to generate new hyphal branches, allowing the fungi to avoid the interaction point and continue invasive growth. Induction of this mechanism was independent of neutrophil NADPH oxidase activity and neutrophil extracellular trap (NET) formation, but could be phenocopied by iron chelation and mechanical or physiological stalling of hyphal tip extension. The consequence of branch induction upon interaction outcome depends on the number and activity of neutrophils available: In the presence of sufficient neutrophils branching makes hyphae more vulnerable to destruction, while in the presence of limited neutrophils the interaction increases the number of hyphal tips, potentially making the infection more aggressive. This has direct implications for infections in neutrophil-deficient patients and opens new avenues for treatments targeting fungal branching.

Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Invasive Pulmonary Aspergillosis after Renal Transplantation Treated by Surgery

Invasive pulmonary aspergillosis is a serious complication in immunocompromised patients. In those unresponsive to pharmacological treatment, or when drug toxicity is excessive, surgery may resolve the condition. A 48-year-old woman with invasive pulmonary aspergillosis after renal transplantation underwent resection of the right upper lobe and the apical segment of the inferior lobe, followed by complete recovery.

Atypical Isolated Infections of the Infratemporal Fossa: A Diagnostic Challenge

INTRODUCTION

Atypical infratemporal fossa infections are rare and potentially fatal.

CASE REPORT

A case of an aspergillosis localized in the infratemporal fossa and another case of tuberculosis of the infratemporal fossa originating from the maxillary sinus, is described. The first patient was immunocompromised and showed symptoms of facial numbness; whereas the other was an immunocompetent man who complained of trigeminal neuralgia type pain. It was difficult to differentiate between infection and tumour despite the utilization of computed tomography scans and magnetic resonance imaging.

CONCLUSION

These cases illustrate the need for a high index of suspicion; in addition to endoscopic confirmation and histopathology to establish precise diagnosis and early intervention.

British Society for Medical Mycology best practice recommendations for the diagnosis of serious fungal diseases

Invasive fungal diseases are an important cause of morbidity and mortality in a wide range of patients, and early diagnosis and management are a challenge. We therefore did a review of the scientific literature to generate a series of key recommendations for the appropriate use of microbiological, histological, and radiological diagnostic methods for diagnosis of invasive fungal diseases. The recommendations emphasise the role of microscopy in rapid diagnosis and identification of clinically significant isolates to species level, and the need for susceptibility testing of all Aspergillus spp, if treatment is to be given. In this Review, we provide information to improve understanding of the importance of antigen detection for cryptococcal disease and invasive aspergillosis, the use of molecular (PCR) diagnostics for aspergillosis, and the crucial role of antibody detection for chronic and allergic aspergillosis. Furthermore, we consider the importance of histopathology reporting with a panel of special stains, and emphasise the need for urgent (<48 hours) and optimised imaging for patients with suspected invasive fungal infection. All 43 recommendations are auditable and should be used to ensure best diagnostic practice and improved outcomes for patients.

Infections in Pediatric Solid Organ Transplant Recipients

Infectious complications are an important cause of morbidity and mortality in children undergoing solid organ transplantation. Knowledge gained over the last 30 years provides a growing understanding of these infections. This review identifies risk factors for and timing of infections describes the common infectious syndromes and pathogens seen in children undergoing solid organ transplantation, and reviews preventive strategies.

Computed tomography-guided percutaneous needle biopsy of indeterminate pulmonary pathology: efficacy of obtaining a diagnostic sample in immunocompetent and immunocompromised patients

PURPOSE

We aimed to evaluate the efficacy of computed tomography (CT)-guided percutaneous lung biopsy of pulmonary nodules with indeterminate radiologic characteristics in patients at risk for malignant and nonmalignant processes such as infection or inflammation.

PATIENTS AND METHODS

From January 2003 to September 2008, 262 patients (mean age, 59 years; range, 18-92 years) with pulmonary nodules or a mass of uncertain etiology and with indeterminate radiologic characteristics underwent CT-guided percutaneous lung biopsy. Patients with discordant clinical history and imaging findings or immunocompromised patients at risk for both etiologies were included. Specimens were submitted for both cytology and microbiology.

RESULTS

Of the entire cohort, 166 patients (63.4%) had a nonmalignant process, and 96 patients (36.6%) had a malignancy. CT-guided percutaneous lung biopsy established a diagnosis in 166 patients (63.4%). Of the 166 patients with a nonmalignant etiology and 96 patients with malignancy, it provided a definitive diagnosis in 91 patients (54.8%) and 75 patients (78.1%), respectively, a difference that was statistically significant (P = .0001). Overall diagnostic efficacy between immunocompetent and immunocompromised patients was comparable (P = .2); however, detection of infection or inflammation in individual groups was lower compared with detection of malignancy (P = .002 and P = .06, respectively).

CONCLUSION

CT-guided percutaneous lung biopsy in patients who are clinically at risk for both nonmalignant and malignant processes continues to be a challenge. Although CT-guided percutaneous biopsy can establish an accurate diagnosis in a large majority of patients with malignancy, it is significantly less sensitive for infectious or inflammatory processes.

Epidemiology of invasive aspergillosis and risk factors in non neutropaenic patients

INTRODUCTION

Invasive aspergillosis is a major cause of mortality in allogeneic bone marrow transplant recipients and patients treated for blood malignancies. The diagnostic tools, treatments and preventive strategies, essentially developed for neutropaenic patients, have not been assessed in populations whose immune systems are considered to be competent.

STATE OF THE ART

Beside the standard picture of chronic Aspergillus infection, the incidence of invasive aspergillosis is increasing in non neutropaenic patients, such as those with chronic lung diseases or systemic disease treated with long-term immunosuppressive drugs and solid organ transplant recipients. This study reviews the specific features of invasive aspergillosis in non neutropaenic subjects (NNS) and discusses the value of the diagnostic tools and treatment in this population.

PROSPECTS

A better understanding of the pathophysiology and the epidemiological characteristics of invasive aspergillosis would provide a means of adapting the staging and classification of the disease for NNS.

CONCLUSIONS

Invasive aspergillosis is under diagnosed in NNS who may already be colonised when they receive immunosuppressive treatment; this can lead to an adverse outcome in patients who are considered to be a moderate risk population.

Pseudoaneurysm of the iliac artery secondary to Aspergillus infection after kidney transplantation

Infectious complications are the top causes of morbidity and mortality in patients who undergo renal transplantation. We report a patient who received a cadaveric renal transplant in Mainland China. One year post-transplantation, the patient had right buttock pain with radiation to the leg. Swelling and tenderness over the right groin was also found. Magnetic resonance imaging revealed a multilobulated cystic lesion, about 8 x 7 cm, at the right iliac fossa and presacral region extending to the posterior aspect of the graft kidney and up to the right psoas muscle. Drainage of the intra-abdominal abscess was performed. The abscess culture showed presence of Aspergillus spp. The patient had received steroids, tacrolimus and mycophenolate mofetil, which could be a risk factor for fungal infection. The cause of Aspergillus infection in our patient remains unclear. It may have been due to immune system insufficiency of the patient rendering the patient prone to infection. Pseudoaneurysm formation of the internal iliac artery following Aspergillus infection after kidney transplantation is rarely reported. Although it is a dilemma, once a severe situation such as pseudoaneurysm with aspergillosis presents, graft removal is suggested.

Pulmonary fungal infections in kidney transplant recipients: an 8-year study

Invasive fungal infections are among the most important causes of mortality among transplant patients. One of the most common manifestations of these infections is pulmonary fungal infection (PFI). The present study sought to evaluate the rate of PFI in kidney transplant patients.

MATERIALS AND METHODS

We retrospectively analyzed the data of 595 patients who underwent kidney transplantation from February 1999 to February 2007. Bronchoalveolar lavage (BAL) culture and tissue biopsy were used to confirm PFI.

RESULTS

Thirteen of 595 patients (2.2%) experienced PFI. The most common pathogen (8/13, 41.5%) was Aspergillus, with 5 (38.5%) infected with Aspergillus only, 2 (15.4%) with both Aspergillus and Candida, and 1 (7.7%) with Aspergillus and mucormycosis. Seven of 13 (53.8%) died and 4 (30.7%) lost the transplanted kidney. Immunosuppressive therapy following rejection and prescription of broad spectrum antibiotics were the most important risk factors for fungal infections in these patients.

CONCLUSIONS

Fungal infections are among the most important causes of mortality among transplant patients, of which the most common manifestation is pulmonary. Immunosuppressive therapy and broad spectrum antibiotics are important risk factors, and Aspergillus is the most common pathogen responsible for fungal infections.

Aspergillus infection limited to the anastomosed artery following renal transplantation: a report of 4 cases

We present 4 cases of Aspergillus fumigatus infection limited to the anastomosed artery following renal transplantation. All grafts were nephrectomized. Two patients received 2 weeks of itraconazole therapy; both showing recurrence of pseudoaneurysms following discontinuation of therapy. Another 2 patients received 3 months of itraconazole therapy without recurrence of pseudoaneurysms. Surgical interventions were life saving. Resection of infected tissues and 3 months of antifungal therapy seemed to give better results than shorter antifungal strategies.

Invasive pulmonary aspergillosis after solid organ transplantation: diagnosis and treatment based on 28 years of transplantation experience

Invasive pulmonary aspergillosis (IPA) is a serious and lethal complication among organ transplant recipients. This report described the clinical manifestations and treatment of IPA over a 28-year period. From January 1979 to December 2007, 3215 organ transplant patients (2954 kidney and 261 liver recipients) were enrolled in the study. Nine patients developed IPA (7 kidney and 2 liver recipients), yielding an incidence of 0.003% (9/3215). Five IPA patients (55.6%) were diagnosed by transbronchial lung biopsy or autopsy, and 3 (33.3%) by sputum culture study. One patient was diagnosed through clinical manifestations and observations of IPA characteristics on chest X ray. We used amphotericin B (n = 4; 44.4%), voriconazole (n = 2; 22.2%), or fluconazole (n = 1; 11.1%) as the primary antifungal agents, but 2 patients could not receive antifungal agents due to rapid disease progression and sequential mortality. This study showed a high mortality rate among IPA patients (55.6%; 5/9). Only patients who received early antifungal agent thereby after a prompt diagnosis recovered from IPA. This survival advantage warrants careful monitoring for invasive fungal infections after organ transplantation with immediate administration of antifungal agents or surgical intervention.

Voriconazole in the Treatment of Invasive Aspergillosis in Kidney Transplant Recipients

BACKGROUND

Aspergillosis and other invasive mold infections are severe complications in immunosuppressed patients, and in renal transplant patients it is the most common cause of systemic fungal disease with an incidence ranging from 0.4% to 2.4% with a high mortality of 56% to 100%. We present our experience with voriconazole in a population of kidney transplant recipients with invasive aspergillosis.

PATIENTS AND METHODS

From January 2002 to December 2005, 245 kidney transplantations were performed.

RESULTS

Four patients (1.6%) presented with clinical and laboratory findings of invasive aspergillosis. Three patients presented with pulmonary aspergillosis, while one patient presented with pulmonary and ocular aspergillosis. All patients underwent a therapy with voriconazole 200 mg twice a day, in combination with caspofungin in one patient. All patients are alive, with no clinical recurrence of aspergillosis at a median follow-up of 13 months. One patient lost her graft due to discontinuation of immunosuppression.

CONCLUSIONS

Voriconazole is a potent and well-tolerated antifungal drug that is extremely efficacious in the treatment of invasive aspergillosis in kidney transplant recipients. A careful monitoring of immunosuppressive drugs should be considered to avoid nephrotoxicity.

Fungal infections in solid organ transplantation

Fungal infections in solid organ transplant recipients continue to be a significant cause of morbidity and mortality. Candida spp. and Aspergillus spp. account for most invasive fungal infections. The incidence of fungal infection varies with type of solid organ transplant. Liver transplant recipients have highest reported incidence of candida infections while lung transplant recipients have highest rate of Aspergillus infections. Recent epidemiological studies suggest the emergence of resistant strains of candida as well as mycelial fungi other than Aspergillus in these patients. The current review incorporates the recent changes in the epidemiology of fungal infections in solid organ transplant recipients and highlights the newer data on the diagnosis, prophylaxis and treatment of fungal infections in these patients.

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.

Antifungal combination therapy: clinical potential

Combination antifungal therapy has been an area of research and clinical interest since systemic antifungals became available decades ago. In vitro and clinical data were generated for some of the more common invasive fungal infections, especially candidiasis, but until very recently few clinical studies were performed. The first invasive fungal infection to be examined in clinical trials with adequate statistical power was cryptococcal meningitis and several of these trials stand out as classical studies in the clinical evaluation of combination antifungal therapy. More recently, since the availability of the newer antifungal agents, including the echinocandins and extended-spectrum triazoles, there has been a growing interest in examining combination antifungal therapy for invasive fungal disease, especially invasive aspergillosis. This is by no means a comprehensive review of all existing experimental data. Instead, the focus is on the clinical data that have been generated to date and on providing insights into potential future clinical directions. For instance, recent clinical data for cryptococcosis confirm that amphotericin B plus flucytosine is the most active combination for patients with cryptococcal meningitis. A recently completed clinical trial in candidaemia suggests a trend towards improved outcomes among patients receiving amphotericin B plus fluconazole versus fluconazole alone. In aspergillosis, several experimental models suggest benefit of a variety of antifungal combinations, but have not been confirmed in prospective clinical trials. Ultimately, the goal is to provide the reader with a comprehensive but useful review to this complicated and often confusing therapeutic dilemma.

Workload due to Aspergillus fumigatus and significance of the organism in the microbiology laboratory of a general hospital

The increase in the immunocompromised population and the incidence of invasive aspergillosis (IA) are leading to an overinterpretation of the potential clinical significance of many isolates of Aspergillus fumigatus. Our work prospectively assesses the workload of the isolation of A. fumigatus and its clinical significance in the microbiology laboratory of a large teaching hospital. During a 3-year period, all patients from whom A. fumigatus was isolated were prospectively monitored and classified as having IA or "nonsignificant" disease. A point score based on the prediction of five easily obtained laboratory and clinical parameters was applied. We found 404 A. fumigatus isolates in 260 patients (1/1,000 microbiology laboratory samples; 2.1 patients/10,000 admissions). A total of 90 isolates (22.3%) were from patients with IA. Of the 260 patients, 31 (12%) had invasive disease (IA), and the remaining 229 had "nonsignificant" disease. A score based on points for five parameters was applied to our population. It was constructed as follows: "sample obtained by invasive procedures" (1 point), "presence of two or more positive samples from the same patient" (1 point), "leukemia" (2 points), "neutropenia" (5 points), and "corticosteroid treatment" (2 points). Patients with a score of 0 had only a 2.5% probability of IA. Those with a score of 1 or 2 had an increased probability of 10.3%. The probabilities rose to 40% and 70%, respectively, for patients with a score of 3 or 4 or a score of > or = 5. A simple score based on five easily available parameters may be of help to microbiologists and clinicians to predict the risk of IA.

Aspergillus infections in transplant recipients

Aspergillus infections are occurring with an increasing frequency in transplant recipients. Notable changes in the epidemiologic characteristics of this infection have occurred; these include a change in risk factors and later onset of infection. Management of invasive aspergillosis continues to be challenging, and the mortality rate, despite the use of newer antifungal agents, remains unacceptably high. Performing molecular studies to discern new targets for antifungal activity, identifying signaling pathways that may be amenable to immunologic interventions, assessing combination regimens of antifungal agents or combining antifungal agents with modulation of the host defense mechanisms, and devising diagnostic assays that can rapidly and reliably diagnose infections represent areas for future investigations that may lead to further improvement in outcomes.

Aspergillus endophthalmitis: an unusual complication of disseminated infection in renal transplant patients

Endogenous Aspergillus endophthalmitis (AE) is a rare complication of invasive aspergillosis (IA) in transplant patients. In this report, we describe two patients with polycystic kidney disease, who developed AE with cerebral involvement after renal transplantation. Both patients received intense immunosuppression with methyl prednisolone and mycophenolate mofitil (MMF) because of persistent rejection, which rendered them diabetic and vulnerable to opportunistic infections. Endophthalmitis developed within six months of transplantation and was confirmed by microscopy and culture of the vitreous fluid. Patients were treated with combinations of different anti-fungal agents including liposomal amphotericin B, 5-flucytosine, itraconazole, voriconazole and terbinafine. In an electronic MEDLINE review, we found eight further cases of AE in renal transplant patients between 1959 and September 2002. Based on this review, we identified possible risk factors including CMV infection, diabetes mellitus and treatment for rejection with agents such as methyl prednisolone and MMF. In 70% of cases the histology, microscopy or culture of vitreous fluid confirmed the diagnosis. The outcome of AE in renal transplant patients was poor with 70-100% mortality. The review of reported cases and current practice guidelines suggests that vitrectomy and intravitreal amphoterecin B is the treatment of choice. In addition, new antifungal agents with good CSF and ocular penetration such as voriconalzole should be considered for the treatment of invasive cerebral/ocular aspergillosis.

The isolation of Aspergillus fumigatus from respiratory tract specimens in heart transplant recipients is highly predictive of invasive aspergillosis

BACKGROUND

Prompt recognition of invasive pulmonary aspergillosis (IPA) after heart transplantation is essential for achieving a successful outcome. However, the significance of the isolation of from respiratory specimens in heart transplant recipients is not established.

METHODS

From 1990 to 1999, we analyzed first respiratory specimens with spp. growth from heart transplant patients in our institution. All specimens were cultured in both fungal and conventional media. Diagnosis of proven and probable IPA or colonization was made according to criteria of the Mycoses Study Group.

RESULTS

During the 10-year study period, spp. was recovered from 30 episodes from 27 heart transplant recipients (incidence: 10.5%). Three episodes were classified as indeterminate and were included in the analysis in a double way, first considering them as true positives and afterward as true negatives, so ranges were obtained. After applying diagnostic criteria, 18 of 30 episodes were proven or probable IPA, and 9 episodes were colonizations. Accordingly, 7 to 8% of heart transplant recipients suffered an IPA, and the overall positive predictive value (PPV) was 60% to 70%. When analyzed by species, the PPV of recovering was 78% to 91%, whereas it was 0% for other species. The PPV increased to 88% to 100% when was recovered from a respiratory specimen other than sputum and decreased to 50% to 67% when it was recovered from sputum. The sensitivities of fungal and conventional media for the recovery of spp. were 95% to 100% and 33% to 38%, respectively.

CONCLUSION

The isolation of from the respiratory tract of a heart transplant recipient is highly predictive of invasive aspergillosis.

Invasive aspergillosis in solid-organ transplantation: report of eight cases and review of the literature

Invasive fungal infections are life-threatening complications in solid-organ transplantation. Although the rate of fungal infections in transplant recipients is lower than that of other infections, the mortality rate is higher. The most frequent fungi isolated from these kinds of infections are Candida spp. and Aspergillus spp. We retrospectively evaluated the clinical and laboratory findings in eight patients who were treated for invasive aspergillosis (IA) at our center. This report describes these cases and discusses the relevant literature.

Oral fungal colonization and oral candidiasis in renal transplant patients: the relationship to Miswak use

OBJECTIVES

The aim of this study was to determine and compare the prevalence of oral candidal colonization and oral candidiasis in a group of medically stable renal transplant patients (RTPs) and age and sex-matched healthy control (HC) subjects.

STUDY DESIGN

The oral cavities of 58 RTPs and 52 HC subjects were clinically examined for the presence of oral candidiasis. Oral fungal colonization was determined by using the concentrated oral rinse technique.

RESULTS

Prevalence of oral fungal colonization was not significantly higher in RTPs than in HC subjects (74.1% vs 59.6%, respectively; P =.1), but the density of growth was significantly higher in RTPs (P <.0017). Oral candidiasis was diagnosed in 15.5% of RTPs but in none of HC subjects (P =.002). RTPs who used a chewing stick (Miswak: Salvadora persica ) for oral hygiene had a significantly lower prevalence of oral candidiasis (P =.04) compared with other RTPs.

CONCLUSIONS

RTPs are at high risk of developing oral candidiasis. More clinical investigations are needed to determine the antimycotic effect of Miswak. Regular oral screening is recommended for RTPs.

Infections in recipients of kidney transplants

A review of infections in kidney transplant recipients is presented in this article, beginning with a discussion of the pretransplant infectious diseases evaluation and an overview of the timing of infectious posttransplant, and then focusing on individual types of infection.

Efficacy and safety of amphotericin B lipid complex injection (ABLC) in solid-organ transplant recipients with invasive fungal infections

BACKGROUND

Fungal infections following solid-organ transplantation are a major source of morbidity and mortality. This report describes the efficacy and safety of Amphotericin B Lipid Complex Injection (ABLC) in solid-organ transplant recipients.

METHODS

Three open-label, second-line treatment studies evaluated ABLC as a treatment for severe, life-threatening mycoses in patients who were refractory to or intolerant to conventional antifungal (mostly amphotericin B [AmB]) therapy or had pre-existing renal disease.

RESULTS

The 79 solid-organ transplant recipients (25 heart, 20 liver, 17 kidney, 11 lung, 5 multiple, 1 pancreas) who received ABLC in these studies had the following fungal infections: aspergillosis (n = 39); candidiasis (n = 20); zygomycosis (n = 8); cryptococcosis and histoplasmosis (n = 3 each); and blastomycosis, cladosporiosis, fusariosis, Bipolaris hawaiiensis, Dactylaria gallopava, and an unspecified fungal infection (n = 1 each). The median duration of ABLC therapy was 28 d (1-178 d). The daily dose ranged between 1.6 and 7.4 mg/kg (median, 4.6 mg/kg). The clinical response rate for the patients who could be assessed was 58% (39/67). Clinical response rates for heart, liver, kidney, and lung recipients were 59, 60, 67, and 40%, respectively; response rates for aspergillosis and candidiasis were 47 and 71%, respectively. Forty-six of the 79 patients (58%) survived for more than 28 d after the last dose of ABLC. Mean baseline serum creatinine was 3.2 mg/dL; 64 patients (81%) had stable (n = 37) or improved (n = 27) serum creatinine at the end of treatment.

CONCLUSIONS

ABLC is safe and effective treatment for fungal infections in solid-organ transplant recipients. Its renal-sparing properties are particularly suited for this high-risk population for renal failure.

Infectious complications in renal transplant recipients

Infectious complications present major challenges to physicians caring for renal transplant recipients. The high rate of infection reflects the net state of immunosuppression associated with end-stage renal disease, transplantation, donor and environmental exposure. An understanding of the factors that affect the patients' overall state of immunosuppression is essential to prevent and treat infectious complications, which may lead to significant morbidity, graft dysfunction, or mortality. Familiarity with the various pathogens, clinical presentation, diagnostic options, treatment, and prophylaxis is important to care for renal transplant patients. The authors present their approach, based on review of current literature, to these issues.

Native lung pneumonectomy for invasive pulmonary aspergillosis following lung transplantation: a case report

Pulmonary aspergillosis occurs most commonly as a consequence of immunosuppression in recipients of pulmonary transplantation and is associated with a high mortality. It affects the native lung more commonly than the transplanted lung in single lung transplant patients. Infection often progresses despite aggressive medical therapy. The cornerstone of treatment of acute, semi-invasive, and invasive pulmonary aspergillosis (IPA) is medical, with intravenous amphotericin B, and oral itraconazole either as isolated or combined therapy. While newer, and more expensive liposomal forms of amphotericin B have been used to enhance tissue penetration and minimize renal toxicity, an appreciable improvement in clinical outcome has not been reported. The role of surgery in localized pulmonary aspergillus infection is well recognized, but remains undefined in immunosuppressed patients. We report a case where a pneumonectomy was performed for progressive, refractory angioinvasive aspergillosis in a lung transplant recipient whose disease progressed despite conventional antifungal therapy.

Chronic Aspergillus sp. meningitis successfully treated with fluconazole. Case report

We a case of chronic Aspergillus sp. meningitis in a healthy 43-year-old woman successfully treated with fluconazole given orally (300 ms/day). The diagnosis was made by detection of anti-aspergillus antibodies and positive culture to Aspergillus sp. in the cerebrospinal fluid.

Invasive aspergillosis in neutropenic patients: rapid neutrophil recovery is a risk factor for severe pulmonary complications

BACKGROUND

In invasive aspergillosis, the duration of neutropenia is an accepted risk factor, and recovery from neutropenia is generally associated with a favourable outcome. However, the rapidity of granulocyte recovery may rarely be associated with adverse sequelae. The purpose of this study was to define the relationship between neutrophil (polymorphonuclear, PMN) recovery after chemotherapy-induced bone marrow aplasia and the occurrence of severe pulmonary complications (haemoptysis, pneumothorax and death) in patients with haematological malignancies who developed invasive fungal pneumonias.

METHODS

Twenty consecutive patients were retrospectively studied; eight of them had developed pulmonary events between 5 and 11 days after neutrophil recovery that followed deep neutropenia (PMN < 100 microL-1).

RESULTS

Five patients had haemoptysis (one of these also had pneumothorax) and three had pneumothorax. According to the multiplicative logistic model, the odds of occurrence of a pulmonary event increased significantly with increasing PMN count on the fifth day (P < 0.001). Five of the eight patients who had pulmonary complications died. Also, the risk of death was larger in the presence of rapid neutrophil recovery, although the difference was not statistically significant (P = 0.111). Analysis of clinical and laboratory data showed that the risk of pulmonary complications significantly increased when the neutrophil concentration was > 4500 microL-1 on day 5 after deep granulocyte neutropenia (PMN < 100 microL-1). There was no correlation between pulmonary complications, dosage of amphotericin B and deaths.

CONCLUSION

The occurrence of life-threatening complications in patients with invasive fungal pneumonia is closely related to rapid PMN recovery.

Primary cutaneous aspergillosis: our experience in 10 years

We describe nine patients with primary cutaneous aspergillosis who were diagnosed during the 10-year period between 1987 and 1996. All except one were adults. Seven of those nine cases had an immunocompromised state. Among the immunocompromised patients, six had burn wounds and one was a renal transplant recipient. Aspergillus flavus was isolated from seven patients and A. fumigatus from one, and in one other case the species could not be determined. Three patients who had total burn surface area of more than 70% died. The other patients responded well to extensive surgical debridement with or without institution of oral itraconazole.

The epidemiology and prevention of invasive aspergillosis

Over the past two decades, the incidence of invasive aspergillosis (IA) has risen inexorably. This is almost certainly the consequence of the more widespread use of aggressive cancer chemotherapy regimens, the expansion of organ transplant programmes and the advent of the acquired immunodeficiency syndrome (AIDS) epidemic. Despite the development of new approaches to therapy, IA still remains a life-threatening infection in immunocompromised patients and is the most important cause of fungal death in cancer patients. It is clear that the prevention of severe fungal infection by the use of effective infection control measure should be the priority of the teams involved in managing at-risk patients. The evidence from clinical and molecular epidemiological studies is reviewed and current thinking on sources and routes of transmission of the organism are discussed. Our increasing understanding of these has led to the development of a variety of environmental and general strategies for the prevention of IA. It is anticipated that these, coupled with the use of prophylactic antifungal agents active against Aspergillus spp., will have a significant impact upon the morbidity and mortality associated with this infection.

Antifungal prophylaxis during neutropenia and immunodeficiency

Fungal infections represent a major source of morbidity and mortality in patients with almost all types of immunodeficiencies. These infections may be nosocomial (aspergillosis) or community acquired (cryptococcosis), or both (candidiasis). Endemic mycoses such as histoplasmosis, coccidioidomycosis, and penicilliosis may infect many immunocompromised hosts in some geographic areas and thereby create major public health problems. With the wide availability of oral azoles, antifungal prophylactic strategies have been extensively developed. However, only a few well-designed studies involving strict criteria have been performed, mostly in patients with hematological malignancies or AIDS. In these situations, the best dose and duration of administration of the antifungal drug often remain to be determined. In high-risk neutropenic or bone marrow transplant patients, fluconazole is effective for the prevention of superficial and/or systemic candidal infections but is not always able to prolong overall survival and potentially selects less susceptible or resistant Candida spp. Primary prophylaxis against aspergillosis remains investigative. At present, no standard general recommendation for primary antifungal prophylaxis can be proposed for AIDS patients or transplant recipients. However, for persistently immunocompromised patients who previously experienced a noncandidal systemic fungal infection, prolonged suppressive antifungal therapy is often indicated to prevent a relapse. Better strategies for controlling immune deficiencies should also help to avoid some potentially life-threatening deep mycoses. When prescribing antifungal prophylaxis, physicians should be aware of the potential emergence of resistant strains, drug-drug interactions, and the cost. Well-designed, randomized, multicenter clinical trials in high-risk immunocompromised hosts are urgently needed to better define how to prevent severe invasive mycoses.