1
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Adam AAN, Mohamed AH, Jeele MOO. A case of varicella zoster infection in kidney transplant recipient using immunosuppressant. Clin Case Rep 2023; 11:e7820. [PMID: 37636872 PMCID: PMC10448235 DOI: 10.1002/ccr3.7820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/08/2023] [Accepted: 07/16/2023] [Indexed: 08/29/2023] Open
Abstract
Kidney transplant recipients must take lifelong immunosuppression to prevent acute or chronic allograft injury. However, they are also at risk for opportunistic infections due to compromised immune cell functionality. Disseminated HZ in kidney transplant recipients can result in a very high overall mortality rate of up to 30%. Here we described a 23-year-old male patient who presented to the emergency room with a complaint of high-grade fever, chills, and non-dermatomal lesion of varicella zoster skin infection that affected the face and trunk. After investigation the patient was diagnosed with chickenpox clinically and was managed with complete recovery and early hospital discharge.
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Affiliation(s)
- Abdirahim Ali Nur Adam
- Department of Infectious DiseaseMogadishu Somali Turkish Training and Research HospitalMogadishuSomalia
| | - Abdulrashid Hashi Mohamed
- Department of Internal MedicineMogadishu Somali Turkish Training and Research HospitalMogadishuSomalia
| | - Mohamed Osman Omar Jeele
- Department of Internal MedicineMogadishu Somali Turkish Training and Research HospitalMogadishuSomalia
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2
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Delayed acyclovir therapy for disseminated varicella zoster in an adult kidney transplant recipient: a case report and literature review. Ann Med Surg (Lond) 2023; 85:481-485. [PMID: 36923769 PMCID: PMC10010797 DOI: 10.1097/ms9.0000000000000231] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 12/25/2022] [Indexed: 03/06/2023] Open
Abstract
Kidney transplant recipients are at increasing risk for reactivation of varicella-zoster virus (VZV) infection. Presentation of case A 31-year-old male was admitted with fever, chest pain, and dyspnea. Also, the complaints accompanied by generalized maculopapular, vesicular, hemorrhagic, itching, and painful rash with pustules and crusts on an erythematous base fill the entire body for the last 10 days. Chest computed tomography scan showed diffuse miliary and ground-glass opacities. The patient had a previous history of chickenpox infection in childhood, no recent contact with individuals suffering from VZV infection, and no known pretransplant serology for VZV. Due to the high clinical suspicion of reactivated VZV with pneumonitis and severe disseminated form, we started the treatment with intravenous acyclovir (ACV) for 10 days followed by oral ACV for a total of 21 days, along with stopping mycophenolate mofetil and increasing the prednisolone dose to 10 mg/d. The clinical status was improved and the rash receded with a flaked surface for old lesions. Conclusion We experienced a successful ACV treatment for delayed and severe VZV infection with a literature review of VZV pneumonitis among kidney transplant recipients. To the best of our knowledge, this is the first case that presented a disseminated skin form with pneumonitis of VZV from Syria. This case supports the initiation of antiviral therapy for transplant patients even after 72 hours the onset of the rash despite the lack of evidence in these circumstances.
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3
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Chuang YW, Huang ST, Wang IK, Lo YC, Chang CT, Lin CL, Yu TM, Li CY. Risk of Severe Alphaherpesvirus Infection after Solid Organ Transplantation: A Nationwide Population-Based Cohort Study. Biomedicines 2023; 11:biomedicines11020637. [PMID: 36831173 PMCID: PMC9953582 DOI: 10.3390/biomedicines11020637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 02/12/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
Patients after solid organ transplantation (SOT) are more susceptible to various viral infections, including alphaherpesviruses. Therefore, the aim of our study was to investigate the risk of alphaherpesvirus infections, including herpes simplex and herpes zoster, after solid organ transplantation. Inpatient records from the Taiwan National Health Insurance Research Database (NHIRD) defined solid organ recipients, including heart, liver, lung, and kidney, hospitalized for alphaherpesvirus infections as a severe case group of transplants and matched them with a nontransplant cohort. We enrolled 18,064 individuals, of whom 9032 were in each group. A higher risk of severe alphaherpesvirus infection was noted in solid organ recipients (aHR = 9.19; p < 0.001) than in the general population. In addition, solid organ transplant recipients had the highest risk of alphaherpesvirus infection within 1 year after transplantation (aHR = 25.18). The comparison found a higher risk of herpes zoster and herpes simplex infections in recipients of kidney (aHR = 9.13; aHR = 12.13), heart (aHR = 14.34; aHR = 18.54), and liver (aHR = 5.90; aHR = 8.28) transplants. Patients who underwent solid organ transplantation had a significantly higher risk of alphaherpesvirus infection than the general population.
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Affiliation(s)
- Ya-Wen Chuang
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404333, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 40227, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- School of Medicine, China Medical University, Taichung 404333, Taiwan
| | - Shih-Ting Huang
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 40227, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- School of Medicine, China Medical University, Taichung 404333, Taiwan
| | - I-Kuan Wang
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404333, Taiwan
- School of Medicine, China Medical University, Taichung 404333, Taiwan
- Division of Nephrology, China Medical University Hospital, Taichung 404333, Taiwan
| | - Ying-Chih Lo
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Chiz-Tzung Chang
- School of Medicine, China Medical University, Taichung 404333, Taiwan
- Division of Nephrology, China Medical University Hospital, Taichung 404333, Taiwan
| | - Cheng-Li Lin
- School of Medicine, China Medical University, Taichung 404333, Taiwan
- Management Office for Health Data, China Medical University Hospital, Taichung 404333, Taiwan
| | - Tung-Min Yu
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404333, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- School of Medicine, China Medical University, Taichung 404333, Taiwan
- Correspondence: (T.-M.Y.); (C.-Y.L.); Tel.: +886-4-2205212 (C.-Y.L.)
| | - Chi-Yuan Li
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404333, Taiwan
- Department of Anesthesiology, China Medical University Hospital, Taichung 404333, Taiwan
- Correspondence: (T.-M.Y.); (C.-Y.L.); Tel.: +886-4-2205212 (C.-Y.L.)
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4
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Authors reply to letter to the editor considering “Ramsay Hunt Syndrome with multiple cranial neuropathy: a literature review”. Eur Arch Otorhinolaryngol 2022; 279:2709-2712. [DOI: 10.1007/s00405-022-07346-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 11/25/2022]
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5
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Harris TN, Szempruch KR, Dupuis RE, Serrano Rodriguez P, Toledo AH. Alemtuzumab in Renal Retransplantation - Transplant Outcomes and Associated Infections. Transplant Proc 2021; 53:2888-2894. [PMID: 34774310 DOI: 10.1016/j.transproceed.2021.08.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/30/2021] [Indexed: 10/19/2022]
Abstract
Renal retransplant patients have decreased graft survival compared with primary renal transplant patients. Alemtuzumab induction is often used at the time of retransplant; however, the literature surrounding alemtuzumab induction in renal retransplant patients is limited. In this single-center, retrospective, observational study, we aimed to determine the 1-year incidence of infections and transplant outcomes in renal retransplant patients who received alemtuzumab induction. Thirty-four patients who received alemtuzumab met inclusion criteria and were included in the final analysis. Twenty-two (64.7%) of these patients acquired infections. Of these, 7 patients (31.8%) acquired infections that resulted in hospitalization or intravenous antibiotics. The most common infections were urinary tract infections (n = 10; 29.4%), cytomegalovirus DNAemia (n = 7; 20.6%), and BK virus (n = 6; 17.6%). The use of steroid maintenance therapy after alemtuzumab induction did not increase the number of infections compared with patients with a steroid-free interval after alemtuzumab induction. The number of patients who developed de novo donor-specific antibodies (DSA) was 11 (32.4%) with only 1 of these patients having DSA before retransplantation. The incidence of acute cellular rejection was 2.9% (n = 1). There was no graft loss, and patient survival was 97% (n = 33). There were no significant differences in infection rate or DSA development between alemtuzumab and the other induction agents, antithymocyte globulin and basiliximab, among retransplanted patients. Alemtuzumab induction in renal retransplant patients resulted in similar bacterial and viral infection rates as previously reported in the literature and did not negatively impact graft and patient survival.
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Affiliation(s)
- Taylor N Harris
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Kristen R Szempruch
- Pharmacy Department, University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Robert E Dupuis
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Pablo Serrano Rodriguez
- Surgery Department - Abdominal Transplant, University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Alexander H Toledo
- Surgery Department - Abdominal Transplant, University of North Carolina Medical Center, Chapel Hill, North Carolina.
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6
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Wang D, Wang JQ, Tao XG. Fatal visceral disseminated varicella-zoster virus infection in a renal transplant recipient: A case report. World J Clin Cases 2021; 9:9168-9173. [PMID: 34786401 PMCID: PMC8567532 DOI: 10.12998/wjcc.v9.i30.9168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/16/2021] [Accepted: 09/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Visceral disseminated varicella-zoster virus (VZV) infection is a rare but life-threatening disease. In transplant recipients with VZV infection, visceral dissemination may develop without skin eruptions, which leads to the failure of early diagnosis.
CASE SUMMARY The patient was a 33-year-old male renal recipient who was referred to our hospital with severe upper abdominal pain of 3-d duration. On admission, the patient rapidly developed septic shock and multiple organ dysfunction syndrome with liver dysfunction and acute kidney injury. Next-generation sequencing of peripheral blood yielded 39224 sequence reads of VZV, and real-time polymerase chain reaction for VZV was positive, with 1.2 × 107 copies/mL. The final diagnosis was visceral disseminated VZV infection. Acyclovir and supportive therapy were started, but the patient died of severe visceral organ damage 16 h after admission.
CONCLUSION Visceral disseminated VZV infection is possible in renal transplant recipients presenting abdominal pain and rapidly-evolving organ damage without skin involvement.
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Affiliation(s)
- Di Wang
- Department of Intensive Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230036, Anhui Province, China
| | - Jin-Quan Wang
- Department of Intensive Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230036, Anhui Province, China
| | - Xiao-Gen Tao
- Department of Intensive Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230036, Anhui Province, China
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7
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Puttarajappa CM, Schinstock CA, Wu CM, Leca N, Kumar V, Vasudev BS, Hariharan S. KDOQI US Commentary on the 2020 KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Am J Kidney Dis 2021; 77:833-856. [PMID: 33745779 DOI: 10.1053/j.ajkd.2020.11.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
Evaluation of patients for kidney transplant candidacy is a comprehensive process that involves a detailed assessment of medical and surgical issues, psychosocial factors, and patients' physical and cognitive abilities with an aim of balancing the benefits of transplantation and potential risks of surgery and long-term immunosuppression. There is considerable variability among transplant centers in their approach to evaluation and decision-making regarding transplant candidacy. The 2020 KDIGO (Kidney Disease: Improving Guidelines Outcome) clinical practice guideline on the evaluation and management of candidates for kidney transplantation provides practice recommendations that can serve as a useful reference guide to transplant professionals. The guideline, covering a broad range of topics, was developed by an international group of experts from transplant and nephrology through a review of literature published until May 2019. A work group of US transplant nephrologists convened by NKF-KDOQI (National Kidney Foundation-Kidney Disease Quality Initiative) chose key topics for this commentary with a goal of presenting a broad discussion to the US transplant community. Each section of this article has a summary of the key KDIGO guideline recommendations, followed by a brief commentary on the recommendations, their clinical utility, and potential implementation challenges. The KDOQI work group agrees broadly with the KDIGO recommendations but also recognizes and highlights the decision-making challenges that arise from lack of high-quality evidence and the need to balance equity with utility of organ transplantation.
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Affiliation(s)
- Chethan M Puttarajappa
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Carrie A Schinstock
- Division of Nephrology & Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Christine M Wu
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Nicolae Leca
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Vineeta Kumar
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Brahm S Vasudev
- Division of Nephrology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Sundaram Hariharan
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA.
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8
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Kho MML, Roest S, Bovée DM, Metselaar HJ, Hoek RAS, van der Eijk AA, Manintveld OC, Roodnat JI, van Besouw NM. Herpes Zoster in Solid Organ Transplantation: Incidence and Risk Factors. Front Immunol 2021; 12:645718. [PMID: 33815403 PMCID: PMC8012754 DOI: 10.3389/fimmu.2021.645718] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/01/2021] [Indexed: 12/20/2022] Open
Abstract
Background Studies on herpes zoster (HZ) incidence in solid organ transplant (SOT) recipients report widely varying numbers. We investigated HZ incidence, severity, and risk factors in recipients of four different SOTs, with a follow-up time of 6-14 years. Methods Records of 1,033 transplant recipients after first heart (HTx: n = 211), lung (LuTx: n = 121), liver (LiTx: n = 258) and kidney (KTx: n = 443) transplantation between 2000 and 2014 were analyzed for VZV-PCR, clinical signs of HZ, and complications. Results HZ was diagnosed in 108 of 1,033 patients (10.5%): 36 HTx, 17 LuTx, 15 LiTx, and 40 KTx recipients. Overall HZ incidence rate after HTx (30.7 cases/1,000 person-years (PY)), LuTx (38.8 cases/1,000 PY), LiTx (22.7 cases/1,000 PY) and KTx (14.5 cases/1,000 PY) was significantly higher than in the general 50-70 year population. Multivariable analysis demonstrated age ≥50 years at transplantation (p = 0.038, RR 1.536), type of organ transplant (overall p = 0.002; LuTx p = 0.393; RR 1.314; LiTx p = 0.011, RR 0.444; KTx p = 0.034, RR 0.575), CMV prophylaxis (p = 0.043, RR 0.631) and type of anti-rejection therapy (overall p = 0.020; methylprednisolone p = 0.008, RR 0.475; r-ATG p = 0.64, RR1.194) as significant risk factors. Complications occurred in 33 of 108 (31%) patients (39% of HTx, 47% of LuTx, 20% of LiTx, 20% of KTx): post-herpetic neuralgia, disseminated disease, and cranial nerve involvement. Conclusion HZ incidence and severity in SOT recipients are most pronounced after heart and lung transplantation, in older patients, and when CMV prophylaxis is lacking.
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Affiliation(s)
- Marcia M L Kho
- Department of Internal Medicine-Nephrology and Transplantation, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands.,Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefan Roest
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Cardiology, Thorax Center, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Dominique M Bovée
- Department of Internal Medicine-Nephrology and Transplantation, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands.,Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Herold J Metselaar
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Rogier A S Hoek
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Respiratory Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Annemiek A van der Eijk
- Department of Viroscience, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Olivier C Manintveld
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Cardiology, Thorax Center, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Joke I Roodnat
- Department of Internal Medicine-Nephrology and Transplantation, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands.,Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Nicole M van Besouw
- Department of Internal Medicine-Nephrology and Transplantation, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands.,Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
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9
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Pittet LF, Danziger-Isakov L, Allen UD, Ardura MI, Chaudhuri A, Goddard E, Höcker B, Michaels MG, Van der Linden D, Green M, Posfay-Barbe KM. Management and prevention of varicella and measles infections in pediatric solid organ transplant candidates and recipients: An IPTA survey of current practice. Pediatr Transplant 2020; 24:e13830. [PMID: 32964637 DOI: 10.1111/petr.13830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/14/2020] [Accepted: 07/28/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Varicella and measles infections can be life-threatening after solid organ transplantation (SOT) but may be preventable with live-attenuated vaccines (LAV). METHODS This survey conducted in January 2019 among subscribers of the International Pediatric Transplantation Association listserv aimed to explore the current strategies to prevent and manage both infections in the pediatric SOT population, including recommending LAV after SOT. RESULTS The answers given by 95 pediatric SOT healthcare workers show that these strategies are not yet optimal and call for further education. In particular, 59% of respondents are unnecessarily waiting for a SOT candidate to be >1 year of age to start administrating LAV before SOT. Interestingly, most respondents are willing to administer LAV after SOT (57%), and a fifth (21%) are already doing so, off-label. The survey queried the precautions taken to improve safety evaluations after LAV, and identified knowledge gaps and practitioners' concerns. CONCLUSION The results of this survey could be used as a starting point for education and promotion of the safe administration of LAV in carefully selected SOT recipients; in turn, this would increase available data that would contribute to the development of evidence-based guidelines by the transplant societies and ultimately prevent these infections after SOT.
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Affiliation(s)
- Laure F Pittet
- Department of Women, Children and Adolescents, Division of General Pediatrics, Children's Hospital, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Lara Danziger-Isakov
- Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, OH, USA
| | - Upton D Allen
- Division of Infectious Diseases, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Monica I Ardura
- Pediatric Infectious Diseases, Host Defense Program, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Abanti Chaudhuri
- Division of Nephrology, Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Elizabeth Goddard
- Department of Paediatrics, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | | | | | - Dimitri Van der Linden
- Pediatric Infectious Diseases, General Pediatrics, Pediatric Department, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Michael Green
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Klara M Posfay-Barbe
- Department of Women, Children and Adolescents, Division of General Pediatrics, Children's Hospital, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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10
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Hanna RM, Abd-El-Malak F, Alnaser A, Cader R, Yabu JM. Herpes Zoster in Kidney Transplant Recipients: A Series of Three Cases. Case Rep Nephrol Dial 2020; 10:139-146. [PMID: 33251251 PMCID: PMC7670328 DOI: 10.1159/000508807] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/14/2020] [Indexed: 02/02/2023] Open
Abstract
Kidney transplant recipients require lifelong immunosuppression to prevent organ rejection. The need for this intervention, however, leads to decreased cellular immunity and, in turn, increased risk of developing herpes zoster (HZ) from reactivation of latent varicella zoster virus. HZ commonly presents as a painful rash in a dermatome presentation followed by post-herpetic neuralgia. In immunosuppressed individuals, the presentation can be atypical and vary in severity depending on degree of immunosuppression and host immune response. We present the clinical course of 3 kidney transplant recipients who developed HZ after transplantation at different times post-transplant with varying clinical manifestations. The balance between maintaining immunosuppression and preventing or subsequently treating disseminated disease is discussed.
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Affiliation(s)
- Ramy M Hanna
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine, Los Angeles, California, USA.,Division of Nephrology, Department of Medicine, University of California Irvine School of Medicine, Orange, California, USA
| | - Farid Abd-El-Malak
- Department of Medicine, David Geffen School of Medicine, Los Angeles, California, USA
| | - Ammar Alnaser
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine, Los Angeles, California, USA
| | - Rumi Cader
- Department of Medicine, David Geffen School of Medicine, Los Angeles, California, USA
| | - Julie M Yabu
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine, Los Angeles, California, USA
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11
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Beyond Cytomegalovirus and Epstein-Barr Virus: a Review of Viruses Composing the Blood Virome of Solid Organ Transplant and Hematopoietic Stem Cell Transplant Recipients. Clin Microbiol Rev 2020; 33:33/4/e00027-20. [PMID: 32847820 DOI: 10.1128/cmr.00027-20] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Viral primary infections and reactivations are common complications in patients after solid organ transplantation (SOT) and hematopoietic stem cell transplantation (HSCT) and are associated with high morbidity and mortality. Among these patients, viral infections are frequently associated with viremia. Beyond the usual well-known viruses that are part of the routine clinical management of transplant recipients, numerous other viral signatures or genomes can be identified in the blood of these patients. The identification of novel viral species and variants by metagenomic next-generation sequencing has opened up a new field of investigation and new paradigms. Thus, there is a need to thoroughly describe the state of knowledge in this field with a review of all viral infections that should be scrutinized in high-risk populations. Here, we review the eukaryotic DNA and RNA viruses identified in blood, plasma, or serum samples of pediatric and adult SOT/HSCT recipients and the prevalence of their detection, with a particular focus on recently identified viruses and those for which their potential association with disease remains to be investigated, such as members of the Polyomaviridae, Anelloviridae, Flaviviridae, and Astroviridae families. Current knowledge of the clinical significance of these viral infections with associated viremia among transplant recipients is also discussed. To ensure a comprehensive description in these two populations, individuals described as healthy (mostly blood donors) are considered for comparative purposes. The list of viruses that should be on the clinicians' radar is certainly incomplete and will expand, but the challenge is to identify those of possible clinical significance.
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12
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Laws HJ, Baumann U, Bogdan C, Burchard G, Christopeit M, Hecht J, Heininger U, Hilgendorf I, Kern W, Kling K, Kobbe G, Külper W, Lehrnbecher T, Meisel R, Simon A, Ullmann A, de Wit M, Zepp F. Impfen bei Immundefizienz. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020; 63:588-644. [PMID: 32350583 PMCID: PMC7223132 DOI: 10.1007/s00103-020-03123-w] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Hans-Jürgen Laws
- Klinik für Kinder-Onkologie, -Hämatologie und Klinische Immunologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Ulrich Baumann
- Klinik für Pädiatrische Pneumologie, Allergologie und Neonatologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Christian Bogdan
- Mikrobiologisches Institut - Klinische Mikrobiologie, Immunologie und Hygiene, Universitätsklinikum Erlangen, Friedrich-Alexander Universität FAU Erlangen-Nürnberg, Erlangen, Deutschland
- Ständige Impfkommission (STIKO), Robert Koch-Institut, Berlin, Deutschland
| | - Gerd Burchard
- Ständige Impfkommission (STIKO), Robert Koch-Institut, Berlin, Deutschland
- Bernhard-Nocht-Institut für Tropenmedizin, Hamburg, Deutschland
| | - Maximilian Christopeit
- Interdisziplinäre Klinik für Stammzelltransplantation, Universitätsklinikum Eppendorf, Hamburg, Deutschland
| | - Jane Hecht
- Abteilung für Infektionsepidemiologie, Fachgebiet Nosokomiale Infektionen, Surveillance von Antibiotikaresistenz und -verbrauch, Robert Koch-Institut, Berlin, Deutschland
| | - Ulrich Heininger
- Ständige Impfkommission (STIKO), Robert Koch-Institut, Berlin, Deutschland
- Universitäts-Kinderspital beider Basel, Basel, Schweiz
| | - Inken Hilgendorf
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Jena, Deutschland
| | - Winfried Kern
- Klinik für Innere Medizin II, Abteilung Infektiologie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - Kerstin Kling
- Abteilung für Infektionsepidemiologie, Fachgebiet Impfprävention, Robert Koch-Institut, Berlin, Deutschland.
| | - Guido Kobbe
- Klinik für Hämatologie, Onkologie und Klinische Immunologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Wiebe Külper
- Abteilung für Infektionsepidemiologie, Fachgebiet Impfprävention, Robert Koch-Institut, Berlin, Deutschland
| | - Thomas Lehrnbecher
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Frankfurt, Frankfurt am Main, Deutschland
| | - Roland Meisel
- Klinik für Kinder-Onkologie, -Hämatologie und Klinische Immunologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Arne Simon
- Klinik für Pädiatrische Onkologie und Hämatologie, Universitätsklinikum des Saarlandes, Homburg/Saar, Deutschland
| | - Andrew Ullmann
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Maike de Wit
- Klinik für Innere Medizin - Hämatologie, Onkologie und Palliativmedizin, Vivantes Klinikum Neukölln, Berlin, Deutschland
- Klinik für Innere Medizin - Onkologie, Vivantes Auguste-Viktoria-Klinikum, Berlin, Deutschland
| | - Fred Zepp
- Ständige Impfkommission (STIKO), Robert Koch-Institut, Berlin, Deutschland
- Zentrum für Kinder- und Jugendmedizin, Universitätsmedizin Mainz, Mainz, Deutschland
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13
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Abstract
Transplants have become common with excellent patient and graft outcomes owing to advances in surgical technique, immunosuppression, and antimicrobial prophylaxis. In 2017, 34,770 solid organ transplants were performed in the United States. For solid organ transplant recipients, infection remains a common complication owing to the regimens required to prevent rejection. Opportunistic infections, which are infections that are generally of lower virulence within a healthy host but cause more severe and frequent disease in immunosuppressed individuals, typically occur in the period 1 month to 1 year after transplantation. This article focuses on opportunistic infections in the solid organ transplant recipient.
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Affiliation(s)
- Rebecca Kumar
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael G Ison
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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14
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Post liver transplant recurrent and de novo viral infections. Best Pract Res Clin Gastroenterol 2020; 46-47:101689. [PMID: 33158469 PMCID: PMC7519014 DOI: 10.1016/j.bpg.2020.101689] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 01/31/2023]
Abstract
Survival following liver transplantation has changed dramatically owing to improvement in surgical techniques, peri-operative care and optimal immunosuppressive therapy. Post-Liver transplant (LT) de novo or recurrent viral infection continues to cause major allograft dysfunction, leading to poor graft and patient survival in untreated patients. Availability of highly effective antiviral drugs has significantly improved post-LT survival. Patients transplanted for chronic hepatitis B infection should receive life-long nucleos(t)ide analogues, with or without HBIg for effective viral control. Patients with chronic hepatitis C should be commenced on directly acting antiviral (DAA) drugs prior to transplantation. DAA therapy for post-LT recurrent hepatitis C infection is associated with close to 100% sustained virological response (SVR), irrespective of genotype. De novo chronic Hepatitis E infection is an increasingly recognised cause of allograft dysfunction in LT recipients. Untreated chronic HEV infection of the graft may lead to liver fibrosis and allograft failure. CMV and EBV can reactivate leading to systemic illness following liver transplantation. With COVID-19 pandemic, post-transplant patients are at risk of SARS-Co-V2 infection. Majority of the LT recipients require hospitalization, and the mortality in this population is around 20%. Early recognition of allograft dysfunction and identification of viral aetiology is essential in the management of post-LT de novo or recurrent infections. Optimising immunosuppression is an important step in reducing the severity of allograft damage in the treatment of post-transplant viral infections. Viral clearance or control can be achieved by early initiation of high potency antiviral therapy.
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15
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Ortiz-Brizuela E, Leal-Vega F, Cuellar-Rodríguez J, Bobadilla-Del-Valle M, Ponce-de-León A. Vaccine-derived varicella zoster infection in a kidney transplant recipient after zoster vaccine live administration. Vaccine 2019; 37:3576-3579. [PMID: 31109718 DOI: 10.1016/j.vaccine.2019.05.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/29/2019] [Accepted: 05/06/2019] [Indexed: 12/26/2022]
Abstract
A 49-year-old kidney transplant recipient, presented with a skin rash, and interstitial infiltrates three weeks after receiving a live attenuated varicella-zoster vaccine. Varicella-zoster Oka-vaccine strain was detected in plasma by polymerase chain reaction and sequencing analysis targeting open reading frame 62 (ORF 62). She was treated successfully with intravenous acyclovir. Our case report supports the current contraindication of live attenuated varicella-zoster vaccine in the solid-organ transplant recipients. Recombinant subunit varicella-zoster vaccine may be the vaccine of choice in these patients; nevertheless, further information is required to establish its safety, efficacy, and optimal timing.
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Affiliation(s)
- Edgar Ortiz-Brizuela
- Laboratory of Clinical Microbiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Avenida Vasco de Quiroga No. 15, Colonia Belisario Domínguez Sección XVI, Delegación Tlalpan, Mexico City 14080, Mexico; Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Avenida Vasco de Quiroga No. 15, Colonia Belisario Domínguez Sección XVI, Delegación Tlalpan, Mexico City 14080, Mexico
| | - Francisco Leal-Vega
- Laboratory of Clinical Microbiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Avenida Vasco de Quiroga No. 15, Colonia Belisario Domínguez Sección XVI, Delegación Tlalpan, Mexico City 14080, Mexico
| | - Jennifer Cuellar-Rodríguez
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Avenida Vasco de Quiroga No. 15, Colonia Belisario Domínguez Sección XVI, Delegación Tlalpan, Mexico City 14080, Mexico
| | - Miriam Bobadilla-Del-Valle
- Laboratory of Clinical Microbiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Avenida Vasco de Quiroga No. 15, Colonia Belisario Domínguez Sección XVI, Delegación Tlalpan, Mexico City 14080, Mexico
| | - Alfredo Ponce-de-León
- Laboratory of Clinical Microbiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Avenida Vasco de Quiroga No. 15, Colonia Belisario Domínguez Sección XVI, Delegación Tlalpan, Mexico City 14080, Mexico; Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Avenida Vasco de Quiroga No. 15, Colonia Belisario Domínguez Sección XVI, Delegación Tlalpan, Mexico City 14080, Mexico.
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16
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Loftus MJ, Yong MK, Wilson S, Peleg AY. Fatal disseminated visceral varicella zoster virus infection in a renal transplant recipient. Transpl Infect Dis 2019; 21:e13062. [PMID: 30756453 DOI: 10.1111/tid.13062] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 01/23/2019] [Accepted: 02/07/2019] [Indexed: 12/12/2022]
Abstract
We report a case of fatal disseminated varicella zoster virus (VZV) with delayed-onset rash in a 66-year-old female more than 2 years following uncomplicated deceased donor renal transplantation. Whilst on a stable regimen of maintenance immunosuppression, the patient presented with chest and abdominal pain with concomitant hepatitis and pancreatitis. After pursuing multiple other potential causes of her symptoms, the correct diagnosis of VZV was only suspected after the development of a widespread vesicular rash-11 days after her initial symptoms. Despite antiviral therapy and inotropic support in the intensive care unit, the patient died. Simultaneous VZV hepatitis and pancreatitis in solid organ transplant recipients is uncommon. The new inactivated VZV vaccines have the potential to prevent post-transplant infections, with promising early clinical data on safety and efficacy in renal transplant recipients. VZV is an important preventable infection that should be considered in immunocompromised patients, even in the absence of rash.
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Affiliation(s)
- Michael J Loftus
- Department of Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia
| | - Michelle K Yong
- Department of Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Scott Wilson
- Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Anton Y Peleg
- Department of Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia.,Department of Microbiology, Infection and Immunity Program, Monash Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
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17
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Lui SL, Yap D, Cheng V, Chan TM, Yuen KY. Clinical practice guidelines for the provision of renal service in Hong Kong: Infection Control in Renal Service. Nephrology (Carlton) 2019; 24 Suppl 1:98-129. [PMID: 30900339 PMCID: PMC7167703 DOI: 10.1111/nep.13497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
| | - Desmond Yap
- Department of MedicineThe University of Hong KongHong Kong
| | - Vincent Cheng
- Department of MicrobiologyQueen Mary HospitalHong Kong
| | - Tak Mao Chan
- Department of MedicineThe University of Hong KongHong Kong
| | - Kwok Yung Yuen
- Department of MicrobiologyThe University of Hong KongHong Kong
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18
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Abstract
With the pervasive nature of chronic kidney disease, kidney transplantation is likely to continue to increase in the coming years. There are many infectious risks related to kidney transplant, including reactivation of latent infections, surgical complications, infectious risks related to immunosuppression, and nosocomial and community-acquired infections. These are described classically via timeline with early infections (first month), middle (1 to 6 months), and late (after 6 months). Kidney transplant patients may suffer from infections secondary to a vast array of organisms, including bacteria, fungi, and viruses. Certain infections, particularly viral infections such as cytomegalovirus, Epstein-Barr virus, and BK virus, may portend acute and chronic implications of the infection and its subsequent impact on graft function. Critical care physicians and nephrologists caring for patients with a renal transplant must understand the broad array of possible infections, atypical presentations, and nuanced implications for appropriate evaluation and subsequent therapy, combined with the need for possible prophylaxis and/or suppression. Multidisciplinary teams, including transplant physicians and infectious diseases physicians, are encouraged strongly.
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19
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Dagenais R, Leung M, Poinen K, Landsberg D. Common Questions and Misconceptions in the Management of Renal Transplant Patients: A Guide for Health Care Providers in the Posttransplant Setting. Ann Pharmacother 2018; 53:419-429. [PMID: 30345802 DOI: 10.1177/1060028018809318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Once renal transplant recipients are stabilized and require less frequent follow-up with their transplant team, health care providers outside of the transplant setting play an integral role in patients' ongoing medical care. Given renal transplant recipients' inherent complexity, these health care providers often seek consult regarding decisions that may affect transplant-related medications or outcomes. In this review, we discuss answers to 10 of the questions commonly posed to our renal transplant team by other health care providers.
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20
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Cutaneous Complications in Recipients of Lung Transplants: A Pictorial Review. Chest 2018; 155:178-193. [PMID: 30201407 DOI: 10.1016/j.chest.2018.08.1060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 08/16/2018] [Indexed: 12/26/2022] Open
Abstract
Lung transplant is now an established modality for a broad spectrum of end-stage pulmonary diseases. According to the International Society for Heart and Lung Transplantation Registry, more than 50,000 lung transplants have been performed worldwide, with nearly 11,000 recipients of lung transplants alive in the United States. With the increasing use of lung transplant, pulmonologists must be cognizant of the common as well as the unique posttransplant dermatologic complications. Immunosuppression, infections, and a variety of medications and environmental exposures can contribute to these complications. This review aims to provide representative pictures and describe the pathogenesis, epidemiologic characteristics, and clinical manifestations of dermatologic complications encountered among recipients of lung transplants.
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21
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Herpes Zoster in Kidney Transplant Recipients: Detection of VZV DNA in Blood During the Prodromal Phase. Transplant Direct 2018; 4:e351. [PMID: 30123824 PMCID: PMC6089518 DOI: 10.1097/txd.0000000000000784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 02/03/2018] [Indexed: 02/01/2023] Open
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22
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Wang L, Verschuuren EAM, van Leer-Buter CC, Bakker SJL, de Joode AAE, Westra J, Bos NA. Herpes Zoster and Immunogenicity and Safety of Zoster Vaccines in Transplant Patients: A Narrative Review of the Literature. Front Immunol 2018; 9:1632. [PMID: 30079064 PMCID: PMC6062765 DOI: 10.3389/fimmu.2018.01632] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 07/02/2018] [Indexed: 12/14/2022] Open
Abstract
This narrative review focuses on the herpes zoster (HZ) and its prevention in transplant patients. Varicella zoster virus (VZV) is highly contagious and distributed worldwide in humans. Primary VZV infection usually causes varicella and then establishes a lifelong latency in dorsal root ganglia. Reactivation of VZV leads to HZ and related complications such as postherpetic neuralgia. Age and decreased immunity against VZV are important risk factors for developing HZ. Transplant patients are at increased risk for developing HZ and related complications due to their immunocompromised status and the need for lifetime immunosuppression. Diagnosis of HZ in transplant patients is often clinically difficult, and VZV-specific antibodies should be determined by serologic testing to document prior exposure to VZV during their pre-transplant evaluation process. Although antiviral agents are available, vaccination should be recommended for preventing HZ in transplant patients considering their complicated condition and weak organ function. Currently, there are two licensed HZ vaccines, of which one is a live-attenuated vaccine and the other is a HZ subunit vaccine. Both vaccines have shown promising safety and efficacy in transplants patients and especially the subunit vaccine could be administered post-transplant since this vaccine does not contain any live virus. Larger studies are needed about safety and immunogenicity of HZ vaccines in transplant populations, and extra efforts are needed to increase vaccine usage according to guidelines.
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Affiliation(s)
- Lei Wang
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Erik A M Verschuuren
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Coretta C van Leer-Buter
- Department of Medical Microbiology, Division of Clinical Virology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stephan J L Bakker
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Anoek A E de Joode
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Johanna Westra
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Nicolaas A Bos
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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23
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Abstract
The good clinical result of lung transplantation is constantly undermined by the high incidence of infection, which negatively impacts on function and survival. Moreover, infections may also have immunological interactions that play a role in the acute rejection and in the development of chronic lung allograft dysfunction. There is a temporal sequence in the types of infection that affects lung allograft: in the first postoperative month bacteria are the most frequent cause of infection; following this phase, cytomegalovirus and Pneumocystis carinii are common. Fungal infections are particularly feared due to their association with bronchial complication and high mortality. Scrupulous postoperative surveillance is mandatory for the successful management of lung transplantation patients with respect to early detection and treatment of infections. This paper is aimed to address clinicians in the management of the major infectious complications that affect the lung transplant population.
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Affiliation(s)
- Mario Nosotti
- Thoracic Surgery and Lung Transplantation Unit, Milano, Italy
| | - Paolo Tarsia
- Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Centre, Ca' Granda Foundation IRCCS Ospedale Maggiore Policlinico, Milano, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | - Letizia Corinna Morlacchi
- Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Centre, Ca' Granda Foundation IRCCS Ospedale Maggiore Policlinico, Milano, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
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24
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Aguilar C, Husain S, Lortholary O. Recent advances in understanding and managing infectious diseases in solid organ transplant recipients. F1000Res 2018; 7. [PMID: 29899970 PMCID: PMC5968357 DOI: 10.12688/f1000research.14262.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2018] [Indexed: 12/30/2022] Open
Abstract
Background: Undergoing solid organ transplantation (SOT) exposes the recipient to various infectious risks, including possible transmission of pathogen by the transplanted organ, post-surgical infections, reactivation of latent pathogens, or novel infections. Recent advances: In the last few years, the emergence of Zika virus has raised concerns in the transplant community. Few cases have been described in SOT patients, and these were associated mainly with moderate disease and favorable outcome; the notable exception is a recent case of fatal meningo-encephalopathy in a heart transplant recipient. Because of the advances in treating hepatitis C, several teams recently started to use organs from hepatitis C-positive donors. The worldwide increasing incidence of multidrug-resistant pathogens, as well as the increasing incidence of
Clostridioides difficile infection, is of particular concern in SOT patients. In the field of mycology, the main recent therapeutic advance is the availability of isavuconazole for the treatment of invasive aspergillosis and mucormycosis. This drug has the advantage of minimal interaction with calcineurin inhibitors. Regarding the viral reactivations occurring after transplant, cytomegalovirus (CMV) infection is still a significant issue in SOT patients. The management of resistant CMV remains particularly difficult. The approval of letermovir, albeit in bone marrow transplantation, and the therapeutic trial of maribavir bring a ray of hope. Another advancement in management of post-transplant infections is the development of
in vitro tests evaluating pathogen-specific immune response, such as immunodiagnostics for CMV and, more recently, tests for monitoring immunity against BK virus. Conclusion: The increasing number of organ transplantations, the use of newer immunosuppressive drugs, and high-risk donors continue to define the landscape of transplant infectious diseases in the current era.
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Affiliation(s)
- Claire Aguilar
- Division of Infectious Diseases, Multi-Organ Transplant Program, Department of Medicine, University of Toronto, University Health Network, Toronto, ON, Canada
| | - Shahid Husain
- Division of Infectious Diseases, Multi-Organ Transplant Program, Department of Medicine, University of Toronto, University Health Network, Toronto, ON, Canada
| | - Olivier Lortholary
- Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Paris Descartes University, IHU Imagine, Paris, France
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25
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Respiratory Viruses and Other Relevant Viral Infections in the Lung Transplant Recipient. LUNG TRANSPLANTATION 2018. [PMCID: PMC7123387 DOI: 10.1007/978-3-319-91184-7_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
As advances occur in surgical technique, postoperative care, and immunosuppressive therapy, the rate of mortality in the early postoperative period following lung transplantation continues to decline. With the improvements in immediate and early posttransplant mortality, infections and their sequel as well as rejection and chronic allograft dysfunction are increasingly a major cause of posttransplant mortality. This chapter will focus on infections by respiratory viruses and other viral infections relevant to lung transplantation, including data regarding the link between viral infections and allograft dysfunction.
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26
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Abstract
The α herpes viruses HSV-1, HSV-2, and VZV often reactivate in the setting of immune suppression after solid organ transplantation. Oral or genital mucocutaneous disease is the most common clinical manifestation of HSV disease while VZV manifests as varicella (or chickenpox) or reactivation herpes zoster, characterized by a diffuse rash, or a painful unilateral vesicular eruption in a dermatomal distribution, respectively. The diagnosis of HSV and VZV is primarily based on history and clinical presentation, although diagnostic tests may be necessary for atypical presentations of disease. Treatment usually involves oral or intravenous antiviral therapy, depending on severity of illness.
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Affiliation(s)
- Cybele Lara Abad
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Raymund R Razonable
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN; The William J. Von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN.
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27
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28
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Maldonado AQ, Johnson D, Trofe-Clark J. Barriers to vaccination in renal transplant recipients. Transpl Infect Dis 2017; 19. [DOI: 10.1111/tid.12749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 04/05/2017] [Accepted: 04/21/2017] [Indexed: 12/19/2022]
Affiliation(s)
| | - David Johnson
- Department of Pharmacy Services; Hospital of the University of Pennsylvania; Philadelphia PA USA
| | - Jennifer Trofe-Clark
- Department of Pharmacy Services; Hospital of the University of Pennsylvania; Philadelphia PA USA
- Renal, Electrolyte Hypertension Division; Perelman School of Medicine; University of Pennsylvania; Philadelphia PA USA
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29
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Helou E, Grant M, Landry M, Wu X, Morrow JS, Malinis MF. Fatal case of cutaneous-sparing orolaryngeal zoster in a renal transplant recipient. Transpl Infect Dis 2017; 19. [PMID: 28401625 DOI: 10.1111/tid.12704] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 10/08/2016] [Accepted: 01/09/2017] [Indexed: 01/04/2023]
Abstract
Herpesvirus infections in solid organ transplant (SOT) recipients are a significant cause of morbidity and mortality. We report a case of herpes zoster (HZ) in a kidney transplant recipient while receiving belatacept, a CTLA-4 inhibitor that prevents acute rejection. The patient presented with oropharyngolaryngeal mucosal lesions that subsequently disseminated resulting in pneumonitis and meningo-encephalitis. Very late-onset HZ can occur and can present atypically in SOT recipients. Delayed recognition and treatment may result in poor outcomes, as illustrated by this case.
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Affiliation(s)
- Elie Helou
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Matthew Grant
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Marie Landry
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Xinyu Wu
- Department of Surgical Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Jon S Morrow
- Department of Surgical Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Maricar F Malinis
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA.,Department of Surgery (Transplant), Yale University School of Medicine, New Haven, CT, USA
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30
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Razonable RR. Liver Transplantation. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00082-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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31
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Abad CL, Razonable RR. Treatment of alpha and beta herpesvirus infections in solid organ transplant recipients. Expert Rev Anti Infect Ther 2016; 15:93-110. [PMID: 27911112 DOI: 10.1080/14787210.2017.1266253] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Human herpesviruses frequently cause infections in solid organ transplant (SOT) recipients. Areas covered: We provide an overview of the clinical impact of alpha and beta herpesviruses and highlight the mechanisms of action, pharmacokinetics, clinical indications, and adverse effects of antiviral drugs for the management of herpes simplex virus, varicella zoster virus and cytomegalovirus. We comprehensively evaluated key clinical trials that led to drug approval, and served as the foundation for management guidelines. We further provide an update on investigational antiviral agents for alpha and beta herpesvirus infections after SOT. Expert commentary: The therapeutic armamentarium for herpes infections is limited by the emergence of drug resistance. There have been major efforts for discovery of new drugs against these viruses, but the results of early-phase clinical trials have been less than encouraging. We believe, however, that more antiviral drug options are needed given the adverse side effects associated with current antiviral agents, and the emergence of drug-resistant virus populations in SOT recipients. Likewise, optimized use and strategies are needed for existing and novel antiviral drugs against alpha and beta-herpesviruses in SOT recipients.
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Affiliation(s)
- C L Abad
- a Division of Infectious Diseases, Department of Medicine , Mayo Clinic , Rochester , MN , USA.,b Department of Medicine, Section of Infectious Diseases , University of the Philippines - Philippine General Hospital , Manila , Philippines
| | - R R Razonable
- a Division of Infectious Diseases, Department of Medicine , Mayo Clinic , Rochester , MN , USA.,c The William J. Von Liebig Center for Transplantation and Clinical Regeneration , Mayo Clinic , Rochester , MN , USA
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32
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Jung D, Kim SH, Choi SO, Park SY. Ramsay Hunt Syndrome in a Living-donor Kidney Transplantation Recipient: Unusual Clinical Course Case. KOREAN JOURNAL OF TRANSPLANTATION 2016. [DOI: 10.4285/jkstn.2016.30.2.86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Dawn Jung
- Department of Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Hoon Kim
- Department of Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seung Ok Choi
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sang You Park
- Department of Otorhinolaryngology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
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Sester M, Leboeuf C, Schmidt T, Hirsch HH. The "ABC" of Virus-Specific T Cell Immunity in Solid Organ Transplantation. Am J Transplant 2016; 16:1697-706. [PMID: 26699950 DOI: 10.1111/ajt.13684] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 12/07/2015] [Accepted: 12/08/2015] [Indexed: 01/25/2023]
Abstract
Transplant patients are at increased risk of viral complications due to impaired control of viral replication, resulting from HLA mismatching between graft and host and the immunosuppression needed to avert alloimmune reactions. In the past decade, quantitative viral load measurements have become widely available to identify patients at risk and to inform treatment decisions with respect to immunosuppressive drugs and antiviral therapies. Because viral loads are viewed as the result of viral replication and virus-specific immune control, virus-specific T cell monitoring has been explored to optimize management of adenovirus, BK polyomavirus and cytomegalovirus ("ABC") in transplant patients. Although most studies are descriptive using different technologies, the overall results show that the quantity and quality of virus-specific T cells inversely correlate with viral replication, whereby strong cellular immune responses are associated with containment of viral replication. The key obstacles to the introduction of assays for virus-specific T cells into clinical practice is the definition of reliable cutoffs for clinical decision making, the poor negative predictive value of some assays, and the absence of interventional trials justifying changes of antiviral treatment or immunosuppression. More clinical research is needed using optimized assays and targets before standardization and commutability can be envisaged as achieved for viral load testing.
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Affiliation(s)
- M Sester
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | - C Leboeuf
- Transplantation & Clinical Virology, Department Biomedicine (Haus Petersplatz), University of Basel, Basel, Switzerland
| | - T Schmidt
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | - H H Hirsch
- Transplantation & Clinical Virology, Department Biomedicine (Haus Petersplatz), University of Basel, Basel, Switzerland.,Division Infection Diagnostics, Department Biomedicine (Haus Petersplatz), University of Basel, Basel, Switzerland.,Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
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Guidelines for vaccination in kidney transplant recipients. Indian J Nephrol 2016. [PMCID: PMC4928525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Barnabas RV, Baeten JM, Lingappa JR, Thomas KK, Hughes JP, Mugo NR, Delany-Moretlwe S, Gray G, Rees H, Mujugira A, Ronald A, Stevens W, Kapiga S, Wald A, Celum C. Acyclovir Prophylaxis Reduces the Incidence of Herpes Zoster Among HIV-Infected Individuals: Results of a Randomized Clinical Trial. J Infect Dis 2016; 213:551-5. [PMID: 26142452 PMCID: PMC4721901 DOI: 10.1093/infdis/jiv318] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 05/27/2015] [Indexed: 12/28/2022] Open
Abstract
Human immunodeficiency virus (HIV)-infected persons have higher rates of herpes zoster than HIV-uninfected individuals. We assessed whether twice daily treatment with 400 mg of oral acyclovir reduces the incidence of herpes zoster in a randomized, double-blind, placebo-controlled trial among 3408 persons coinfected with HIV and herpes simplex virus type 2. During 5175 person-years of follow-up, 26 cases of herpes zoster occurred among those assigned acyclovir, compared with 69 cases among those assigned placebo (rates, 1.00 and 2.68/100 person-years, respectively), a relative decrease of 62% (hazard ratio, 0.38; 95% confidence interval, .24-.67; P < .001). Daily acyclovir prophylaxis significantly reduced herpes zoster incidence among HIV-infected persons.
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Affiliation(s)
- Ruanne V Barnabas
- Department of Global Health, University of Washington Department of Medicine, University of Washington Department of Epidemiology, University of Washington Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jared M Baeten
- Department of Global Health, University of Washington Department of Medicine, University of Washington Department of Epidemiology, University of Washington
| | - Jairam R Lingappa
- Department of Global Health, University of Washington Department of Medicine, University of Washington
| | | | - James P Hughes
- Department of Biostatistics, University of Washington Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Nelly R Mugo
- Department of Global Health, University of Washington
| | | | - Glenda Gray
- Perinatal HIV Research Unit, Soweto, South Africa
| | - Helen Rees
- Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg
| | - Andrew Mujugira
- Department of Global Health, University of Washington Department of Epidemiology, University of Washington
| | - Allan Ronald
- Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - Wendy Stevens
- Department of Molecular Medicine and Haematology, University of Witwatersrand, Johannesburg
| | - Saidi Kapiga
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Anna Wald
- Department of Global Health, University of Washington Department of Medicine, University of Washington Department of Laboratory Medicine, University of Washington Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Connie Celum
- Department of Global Health, University of Washington Department of Medicine, University of Washington Department of Epidemiology, University of Washington
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Hernandez MDP, Martin P, Simkins J. Infectious Complications After Liver Transplantation. Gastroenterol Hepatol (N Y) 2015; 11:741-753. [PMID: 27134589 PMCID: PMC4849501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Orthotopic liver transplantation (OLT) is the standard of care for patients with decompensated cirrhosis and for patients with hepatocellular carcinoma. More than 6000 liver transplants are performed annually in the United States. High patient and graft survival rates have been achieved in great part due to the availability of potent immunosuppressive agents. Systemic immunosuppression has rendered the liver recipient susceptible to de novo infections as well as reactivation of preexisting latent infections. Infections occurring during the first month post-OLT are usually nosocomial, donor-derived, or the result of a perioperative complication. The development of opportunistic infections (OIs) such as Aspergillus and the reactivation of latent infections such as Mycobacterium tuberculosis are more frequent 1 to 6 months posttransplant, when the net state of immunosuppression is the highest. Immunosuppressive therapy is tapered 6 to 12 months post-OLT; therefore, infections occurring during that time period and afterward generally resemble those of the general population. Screening strategies applied to determine the risk of an infection after transplantation and the use of prophylactic antimicrobial therapy have reduced the incidence of OIs after OLT. This article will review the various causes of infection post-OLT and the therapies used to manage complications.
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Affiliation(s)
- Maria Del Pilar Hernandez
- Dr Hernandez is an assistant professor of medicine and Dr Martin is a professor of medicine in the Division of Hepatology at the University of Miami Miller School of Medicine in Miami, Florida. Dr Simkins is an assistant professor of medicine in the Division of Infectious Diseases at the University of Miami Miller School of Medicine
| | - Paul Martin
- Dr Hernandez is an assistant professor of medicine and Dr Martin is a professor of medicine in the Division of Hepatology at the University of Miami Miller School of Medicine in Miami, Florida. Dr Simkins is an assistant professor of medicine in the Division of Infectious Diseases at the University of Miami Miller School of Medicine
| | - Jacques Simkins
- Dr Hernandez is an assistant professor of medicine and Dr Martin is a professor of medicine in the Division of Hepatology at the University of Miami Miller School of Medicine in Miami, Florida. Dr Simkins is an assistant professor of medicine in the Division of Infectious Diseases at the University of Miami Miller School of Medicine
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Abstract
PURPOSE OF REVIEW Immunosuppressive treatments increase the life-long risk of solid organ transplant (SOT) recipients for severe infections, some of which are vaccine-preventable. In this review of the literature published during the last 15 months, we critically summarize vaccine-oriented articles in SOT candidates or recipients. Because of previously reported differences, vaccine-specific studies are needed for each type of SOT recipients. RECENT FINDINGS Thanks to new data gathered during the H1N1/2009 influenza pandemic, recent research mainly focused on influenza vaccination, especially in kidney transplantation. Lung transplantation, mycophenolate treatment, increasing age and end-stage organ failure were frequently identified as risk factors for nonresponse to immunization in general. New evidence concerning the safety of immunizing SOT recipients with live-attenuated vaccines is obtained. SUMMARY During this last year, more encouraging data have been published regarding safety and immunogenicity of vaccination in SOT recipients. New inventive strategies should be studied to overcome missed opportunities for vaccinating SOT candidates and recipients, and to promote the most effective vaccination schedule and follow-up.
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Abstract
Solid organ transplantation (SOT) is one of the major advances in medicine. Care of the SOT recipient is complex and continued partnership with the transplant specialist is essential to manage and treat complications and maintain health. The increased longevity of SOT recipients will lead to their being an evolving part of primary care practice, with ever more opportunities for care, education, and research of this rewarding patient population. This review discusses the overall primary care management of adult SOT recipients.
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Affiliation(s)
- Christopher J Wong
- Division of General Internal Medicine, Department of Medicine, University of Washington, 4245 Roosevelt Way Northeast, Box 354760, Seattle, WA 98105, USA.
| | - Genevieve Pagalilauan
- Division of General Internal Medicine, Department of Medicine, University of Washington, 4245 Roosevelt Way Northeast, Box 354760, Seattle, WA 98105, USA
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Pavlopoulou ID, Poulopoulou S, Melexopoulou C, Papazaharia I, Zavos G, Boletis IN. Incidence and risk factors of herpes zoster among adult renal transplant recipients receiving universal antiviral prophylaxis. BMC Infect Dis 2015. [PMID: 26204926 PMCID: PMC4513398 DOI: 10.1186/s12879-015-1038-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background Herpes zoster (HZ) is a significant cause of morbidity and complications in adult renal transplant recipients. We determined the incidence, complications and risk factors for the development of HZ after renal transplantation in a setting using universal antiviral prophylaxis. Methods The medical files of all adult renal transplants, performed between 2004 and 2008, were retrospectively reviewed to assess the clinical characteristics and risk factors of HZ. Incident cases of HZ were determined and the probability of developing post-transplant HZ for all subjects was calculated using the Kaplan Meier method. A multivariable Cox proportional hazards model was applied to assess the risk factors associated with the development of HZ. Results A total of 450 patients were eligible with a median follow up of 38 months. Twenty nine subjects (6.4 %) developed HZ, the median time to onset was 18 months, only three of them (10.3 %) required hospitalization, and none developed disseminated or visceral disease and death directly attributed to zoster. However, high rates of post-herpetic neuralgia (48.7 %) were observed. Overall incidence was calculated at 20.6 cases per 1000 patient-years of follow-up. Following multivariate analysis, increased age ≥ 60 years old, positive pre-transplant history of varicella related disease and administration of rejection treatment conferred an increased risk of 4.00-fold (CI: 1.79- 8.92), 16.00-fold (CI: 4.62- 55.52), and 5.57-fold (CI: 1.56- 19.84) respectively, for the development of post-transplant zoster. Conclusions HZ remains a common complication after renal transplantation in adults under current immunosuppession protocols and universal antiviral prophylaxis. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-1038-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ioanna D Pavlopoulou
- Paediatric Research Laboratory, National and Kapodistrian University of Athens, Faculty of Nursing, Athens, Greece.
| | | | - Christina Melexopoulou
- Renal Transplant Unit, "Laiko" General Hospital, National and Kapodistrian University, Faculty of Medicine, Athens, Greece.
| | - Ioanna Papazaharia
- Postgraduate Program, National and Kapodistrian University of Athens, Faculty of Nursing, Athens, Greece.
| | - George Zavos
- Renal Transplant Unit, "Laiko" General Hospital, National and Kapodistrian University, Faculty of Medicine, Athens, Greece.
| | - Ioannis N Boletis
- Renal Transplant Unit, "Laiko" General Hospital, National and Kapodistrian University, Faculty of Medicine, Athens, Greece.
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