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Patel K, Twohig P, Peeraphatdit T, Stohs EJ, Samson K, Smith L, Patel J, Manatsathit W. Outcomes and factors associated with cryptococcal disease among cirrhotics: A study of the national inpatient sample 2005 to 2014. Clin Res Hepatol Gastroenterol 2024; 48:102337. [PMID: 38609048 DOI: 10.1016/j.clinre.2024.102337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/29/2024] [Accepted: 04/05/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Cryptococcal disease (CD) confers a higher mortality in cirrhotic patients compared to non-cirrhotic patients. Factor association for CD in cirrhotic patients is poorly understood. Our aim was to determine the incidence, demographic, and comorbidities associated with CD among cirrhotic patients in the United States (US). METHOD Retrospective analysis of admissions of cirrhotic patients, with or without CD, using the National Inpatient Sample (NIS) database from 2005 to 2014. The number of admissions were reported in raw and weighted frequencies. The trends of CD among cirrhotic patients and overall CD were evaluated. Rao-Scott chi-square, t-tests, and multivariate logistic regressions were performed to evaluate variables and CD among cirrhotic patients. RESULTS There were 886,962 admissions for cirrhosis, and 164 of these with CD. By adjusted odds ratio (AOR), CD was more often associated with cirrhosis in Southern (2.95; 95 % CI 1.24, 7.02) and Western regions (4.45; 95 % CI 1.91, 10.37), Hispanic patients (1.80; 95 % CI 1.01, 3.20), and patients with chronic kidney disease (CKD) (3.13; 95 % CI 2.09, 4.69). Of note, CD in cirrhotic patients was associated with higher inpatient mortality (AOR of 3.89, 95 % CI 2.53, 5.99), longer length of stay (9.87 vs. 4.88 days), and a higher total charge ($76,880 vs. $ 37,227) when compared to cirrhotic patients without CD. DISCUSSION Patients with cirrhosis admitted with CD have a high inpatient mortality. The geographical location and CKD were important factors associated with CD among cirrhotic patients. Autoimmune liver diseases and immunosuppression did not appear to increase the risk of CD.
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Affiliation(s)
- Kishan Patel
- Division of Gastroenterology and Nutrition, Loyola University Medical Center, Maywood, IL 60153, USA
| | - Patrick Twohig
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Thoetchai Peeraphatdit
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Erica J Stohs
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Kaeli Samson
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Lynette Smith
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Jay Patel
- Department of Internal Medicine, University of Connecticut Medical Center, Farmington, CA 06030, USA
| | - Wuttiporn Manatsathit
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE 68198, USA.
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Meena P, Bhargava V, Singh K, sethi J, Prabhakar A, panda S. Cryptococcosis in kidney transplant recipients: Current understanding and practices. World J Nephrol 2023; 12:120-131. [PMID: 38230297 PMCID: PMC10789088 DOI: 10.5527/wjn.v12.i5.120] [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: 08/03/2023] [Revised: 10/15/2023] [Accepted: 11/02/2023] [Indexed: 12/22/2023] Open
Abstract
Cryptococcosis is the third most commonly occurring invasive fungal disease in solid organ transplant recipients (SOT). It is caused by encapsulated yeast, Cryptococcus species, predominantly Cryptococcus neoformans and Cryptococcus gattii. Though kidney transplant recipients are at the lowest risk of cryptococcosis when compared to other solid organ transplant recipients such as lung, liver or heart, still this opportunistic infection causes significant morbidity and mortality in this subset of patients. Mortality rates with cryptococcosis range from 10%-25%, while it can be as high as 50% in SOT recipients with central nervous system involvement. The main aim of diagnosis is to find out if there is any involvement of the central nervous system in disseminated disease or whether there is only localized pulmonary involvement as it has implications for both prognostication and treatment. Detection of cryptococcal antigen (CrAg) in cerebrospinal fluid or plasma is a highly recommended test as it is more sensitive and specific than India ink and fungal cultures. The CrAg lateral flow assay is the single point of care test that can rapidly detect cryptococcal polysaccharide capsule. Treatment of cryptococcosis is challenging in kidney transplant recipients. Apart from the reduction or optimization of immunosuppression, lipid formulations of amphotericin B are preferred as induction antifungal agents. Consolidation and maintenance are done with fluconazole; carefully monitoring its interactions with calcineurin inhibitors. This review further discusses in depth the evolving developments in the epidemiology, pathogenesis, diagnostic assays, and management approach of cryptococcosis in kidney transplant recipients.
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Affiliation(s)
- Priti Meena
- Department of Nephrology, All India Institute of Medical Sciences, Bhubaneswar 751019, Odhisha, India
| | - Vinant Bhargava
- Department of Nephrology, Sir Ganga Ram Hospital New Delhi, New Delhi 110001, New Delhi, India
| | - Kulwant Singh
- Department of Nephrology, Ivy Hospital, Mohali Punjab, Mohali 160071, Punjab, India
| | - Jasmine sethi
- Department of Nephrology, Post Graduate Institute of Medical Education & Research, Chandigarh 160012, Punjab, India
| | - Aniketh Prabhakar
- Department of Nephrology, Consultant Nephrologist, Sigma Hospital, Mysore 570009, Karnataka, India
| | - Sandip panda
- Department of Nephrology, All India Institute of Medical Sciences, Bhubaneswar 751019, Odhisha, India
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Lu YA, Lin CH, Chang CJ, Shu KH, Chung MC, Chou CC. Non-meningeal, non-pulmonary cryptococcosis with limited posterior uveitis in a kidney organ transplant recipient with antibody-mediated rejection: a case report. BMC Ophthalmol 2023; 23:409. [PMID: 37817150 PMCID: PMC10565975 DOI: 10.1186/s12886-023-03130-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 09/11/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Cryptococcosis is one of the most frequent fungal eye infections in patients with immunosuppression. Currently, treatment approaches for non-meningeal, non-pulmonary cryptococcosis are based on those used for cryptococcal meningitis or pneumonia. CASE PRESENTATION We present a rare case of non-meningeal, non-pulmonary cryptococcosis with clinical manifestations limited to one eye of a cadaveric kidney transplant recipient with chronic-active antibody-mediated rejection. Typical manifestations, diagnosis, and treatments, including antifungal therapies, adjunctive therapies, and immunosuppression reduction, are discussed. After timely diagnosis and treatment, her visual acuity recovered to baseline without recurrence or sequelae of cryptococcosis. CONCLUSIONS Clinicians should be aware of rare presentations of fungal infections, especially when a kidney transplant recipient with rejection has been treated with intensive immunosuppressants. Early diagnosis with individualized therapies may have a favorable prognosis.
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Affiliation(s)
- Yi-An Lu
- Department of Ophthalmology, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 407219, Taiwan
| | - Chun-Hsien Lin
- Department of Ophthalmology, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 407219, Taiwan
| | - Chia-Jen Chang
- Department of Ophthalmology, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 407219, Taiwan
| | - Kuo-Hsiung Shu
- Division of Nephrology, Department of Internal Medicine, Lin Shin Hospital, No.36, Sec. 3, Huizhong Rd., Nantun District, Taichung City, 40867, Taiwan
| | - Mu-Chi Chung
- Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 407219, Taiwan.
- PhD Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan.
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan.
- Department of Medical Laboratory Science and Biotechnology, Asia University, Taichung, Taiwan.
| | - Chien-Chih Chou
- Department of Ophthalmology, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 407219, Taiwan.
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- College of Medicine, National Chung Hsing University, Taichung, Taiwan.
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Macrae C, Ellis J, Keddie SH, Falconer J, Bradley J, Keogh R, Baerenbold O, Hopkins H, Jarvis JN. Diagnostic performance of the IMMY cryptococcal antigen lateral flow assay on serum and cerebrospinal fluid for diagnosis of cryptococcosis in HIV-negative patients: a systematic review. BMC Infect Dis 2023; 23:209. [PMID: 37024842 PMCID: PMC10080957 DOI: 10.1186/s12879-023-08135-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/03/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND The incidence of cryptococcosis amongst HIV-negative persons is increasing. Whilst the excellent performance of the CrAg testing in people living with HIV is well described, the diagnostic performance of the CrAg LFA has not been systematically evaluated in HIV-negative cohorts on serum or cerebrospinal fluid. METHODS We performed a systematic review to characterise the diagnostic performance of IMMY CrAg® LFA in HIV-negative populations on serum and cerebrospinal fluid. A systematic electronic search was performed using Medline, Embase, Global Health, CENTRAL, WoS Science Citation Index, SCOPUS, Africa-Wide Information, LILACS and WHO Global Health Library. Studies were screened and data extracted from eligible studies by two independent reviewers. A fixed effect meta-analysis was used to estimate the diagnostic sensitivity and specificity. RESULTS Of 447 records assessed for eligibility, nine studies met our inclusion criteria, including 528 participants overall. Amongst eight studies that evaluated the diagnostic performance of the IMMY CrAg® LFA on serum, the pooled median sensitivity was 96% (95% Credible Interval (CrI) 68-100%) with a pooled specificity estimate of 96% (95%CrI 84-100%). Amongst six studies which evaluated the diagnostic performance of IMMY CrAg® LFA on CSF, the pooled median sensitivity was 99% (95%CrI 95-100%) with a pooled specificity median of 99% (95%CrI 95-100%). CONCLUSIONS This review demonstrates a high pooled sensitivity and specificity for the IMMY CrAg® LFA in HIV-negative populations, in keeping with findings in HIV-positive individuals. The review was limited by the small number of studies. Further studies using IMMY CrAg® LFA in HIV-negative populations would help to better determine the diagnostic value of this test.
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Affiliation(s)
- Catriona Macrae
- Infectious Diseases Unit, NHS Lanarkshire, University Hospital Monklands, Monkscourt Avenue, Airdrie, ML6 0JS UK
| | - Jayne Ellis
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
- Infectious Diseases Institute, Makerere University, PO Box 22418, Kampala, Uganda
| | - Suzanne H. Keddie
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Jane Falconer
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - John Bradley
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Ruth Keogh
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Oliver Baerenbold
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Heidi Hopkins
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Joseph N. Jarvis
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
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5
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Li K, Khan A, Mishra S, Zhabokritsky A. Disseminated cryptococcal infection in a patient with a remote renal transplant. CMAJ 2021; 193:E211-E214. [PMID: 33558407 PMCID: PMC7954546 DOI: 10.1503/cmaj.200825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Kelli Li
- Divisions of General Internal Medicine (Li), Nephrology (Khan) and Infectious Diseases (Mishra, Zhabokritsky), Department of Medicine, Faculty of Medicine, University of Toronto; Division of Infectious Diseases (Mishra), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Abid Khan
- Divisions of General Internal Medicine (Li), Nephrology (Khan) and Infectious Diseases (Mishra, Zhabokritsky), Department of Medicine, Faculty of Medicine, University of Toronto; Division of Infectious Diseases (Mishra), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Sharmistha Mishra
- Divisions of General Internal Medicine (Li), Nephrology (Khan) and Infectious Diseases (Mishra, Zhabokritsky), Department of Medicine, Faculty of Medicine, University of Toronto; Division of Infectious Diseases (Mishra), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Alice Zhabokritsky
- Divisions of General Internal Medicine (Li), Nephrology (Khan) and Infectious Diseases (Mishra, Zhabokritsky), Department of Medicine, Faculty of Medicine, University of Toronto; Division of Infectious Diseases (Mishra), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.
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6
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Li K, Khan A, Mishra S, Zhabokritsky A. Cryptococcose disséminée chez une greffée rénale de longue date. CMAJ 2021; 193:E585-E588. [PMID: 33875468 PMCID: PMC8084560 DOI: 10.1503/cmaj.200825-f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Kelli Li
- Divisions de médecine interne générale (Li), de néphrologie (Khan) et d'infectiologie (Mishra, Zhabokritsky), Département de médecine, Faculté de médecine, Université de Toronto; Division d'infectiologie (Mishra), Service de médecine, Hôpital St. Michael, Unity Health Toronto, Toronto, Ont
| | - Abid Khan
- Divisions de médecine interne générale (Li), de néphrologie (Khan) et d'infectiologie (Mishra, Zhabokritsky), Département de médecine, Faculté de médecine, Université de Toronto; Division d'infectiologie (Mishra), Service de médecine, Hôpital St. Michael, Unity Health Toronto, Toronto, Ont
| | - Sharmistha Mishra
- Divisions de médecine interne générale (Li), de néphrologie (Khan) et d'infectiologie (Mishra, Zhabokritsky), Département de médecine, Faculté de médecine, Université de Toronto; Division d'infectiologie (Mishra), Service de médecine, Hôpital St. Michael, Unity Health Toronto, Toronto, Ont
| | - Alice Zhabokritsky
- Divisions de médecine interne générale (Li), de néphrologie (Khan) et d'infectiologie (Mishra, Zhabokritsky), Département de médecine, Faculté de médecine, Université de Toronto; Division d'infectiologie (Mishra), Service de médecine, Hôpital St. Michael, Unity Health Toronto, Toronto, Ont.
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7
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Long-Term Infectious and Noninfectious Outcomes of Monthly Alemtuzumab as a Calcineurin Inhibitor- and Steroid-Free Regimen for Pancreas Transplant Recipients. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2020; 2020:8883183. [PMID: 33101558 PMCID: PMC7569440 DOI: 10.1155/2020/8883183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/22/2020] [Accepted: 09/28/2020] [Indexed: 11/18/2022]
Abstract
Multiple doses of alemtuzumab for immunosuppressive therapy of patients with hematologic malignancies and hematopoietic stem cell transplant have been associated with a high rate of infection. In transplantation, limited alemtuzumab dosing has been successfully used as induction immunosuppression. The effect of multiple doses of alemtuzumab, used as maintenance therapy to minimize steroid and/or calcineurin inhibitor toxicity in solid organ transplant recipients, is unknown. We evaluated the infectious and noninfectious outcomes of 179 pancreas transplant recipients treated with alemtuzumab for induction and maintenance therapy (extended alemtuzumab exposure (EAE)) from 2/28/2003 through 8/31/2005, compared with 159 pancreas transplant recipients with standard induction and maintenance (SIM) therapy performed before (1/1/2002 until 12/31/2002) and after (1/1/2006 until 12/31/2006) the implementation of EAE. EAE was associated with higher risk of overall infections (hazard ratio (HR) 1.33 (1.06–1.66), P=0.01), bacterial infections (HR 1.33 (1.05–1.67), P=0.02), fungal infections (HR 1.86 (1.28–2.71), P < 0.01), and cytomegalovirus infections (HR 2.29 (1.39–3.77), P < 0.01). In addition, EAE was associated with higher risk of acute cellular rejection (HR 2.09 (1.46–2.99), P < 0.01). In conclusion, while a limited alemtuzumab dosing is safe and effective for induction therapy in pancreas transplantation, EAE combined with steroid and calcineurin minimization is associated with a high risk of infectious complications and acute cellular rejection.
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Passarelli VC, Perosa AH, de Souza Luna LK, Conte DD, Nascimento OA, Ota-Arakaki J, Bellei N. Detected SARS-CoV-2 in Ascitic Fluid Followed by Cryptococcemia: a Case Report. ACTA ACUST UNITED AC 2020; 2:2414-2418. [PMID: 33047097 PMCID: PMC7541755 DOI: 10.1007/s42399-020-00574-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2020] [Indexed: 12/24/2022]
Abstract
SARS coronavirus-2 (SARS-CoV-2) detection in different clinical specimens has raised important insights about its pathogenesis, but some details remain to be understood. In that respect, disrupt viral control seen in solid organ transplant patients on chronic immunosuppression can help unveil pathogenic mechanisms and characterize new coronavirus disease-19 (COVID-19) immunological and clinical aspects, as well as secondary complications. We herein report a case of SARS-CoV-2 detection in ascitic fluid from a kidney transplant patient with decompensated cirrhosis and COVID-19 and then discuss about immune, cellular, and virological aspects of such clinical presentation of the disease, which also included a disseminated infection, demonstrated by viral detection in his blood sample. We subsequently discuss about the fatal outcome caused by a secondary bloodstream infection by Cryptococcus neoformans. This unprecedented case report presents ascitic fluid as a novel specimen in which SARS-CoV-2 can be detected. Immune dysregulation and cumulative risk factors may lead to secondary infections by opportunistic agents, including Cryptococcus neoformans.
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Affiliation(s)
- Victor C Passarelli
- Infectious Diseases Division, Department of Medicine, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
| | - Ana H Perosa
- Infectious Diseases Division, Department of Medicine, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
| | - Luciano Kleber de Souza Luna
- Infectious Diseases Division, Department of Medicine, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
| | - Danielle D Conte
- Infectious Diseases Division, Department of Medicine, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
| | - Oliver A Nascimento
- Pulmonology Division, Department of Medicine, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
| | - Jaquelina Ota-Arakaki
- Pulmonology Division, Department of Medicine, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
| | - Nancy Bellei
- Infectious Diseases Division, Department of Medicine, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil
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9
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Cryptococcosis in Liver Transplant Candidates and Recipients. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00399-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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10
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Setianingrum F, Rautemaa-Richardson R, Denning DW. Pulmonary cryptococcosis: A review of pathobiology and clinical aspects. Med Mycol 2019; 57:133-150. [PMID: 30329097 DOI: 10.1093/mmy/myy086] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 09/05/2018] [Indexed: 01/13/2023] Open
Abstract
Pulmonary cryptococcosis is an important opportunistic invasive mycosis in immunocompromised patients, but it is also increasingly seen in immunocompetent patients. The main human pathogens are Cryptococcus neoformans and C. gattii, which have a worldwide distribution. In contrast to cryptococcal meningitis, pulmonary cryptococcosis is still underdiagnosed because of limitations in diagnostic tools. It can mimic lung cancer, pulmonary tuberculosis, bacterial pneumonia, and other pulmonary mycoses both clinically and radiologically. Pulmonary nodules are the most common radiological feature, but these are not specific to pulmonary cryptococcosis. The sensitivity of culture of respiratory samples for Cryptococcus is poor and a positive result may also reflect colonisation. Cryptococcal antigen (CrAg) with lateral flow device is a fast and sensitive test and widely used on serum and cerebrospinal fluid, but sera from patients with pulmonary cryptococcosis are rarely positive in the absence of disseminated disease. Detection of CrAg from respiratory specimens might assist the diagnosis of pulmonary cryptococcosis but there are very few data. Molecular detection techniques such as multiplex reverse transcription polymerase chain reaction (RT-PCR) could also provide better sensitivity but these still require validation for respiratory specimens. The first line of treatment for pulmonary cryptococcosis is fluconazole, or amphotericin B and flucytosine for those with central nervous system involvement. Pulmonary cryptococcosis worsens the prognosis of cryptococcal meningitis. In this review, we summarize the biological aspects of Cryptococcus and provide an update on the diagnosis and management of pulmonary cryptococcosis.
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Affiliation(s)
- Findra Setianingrum
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, UK
- Parasitology Department, Universitas Indonesia, Jakarta, Indonesia
| | - Riina Rautemaa-Richardson
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, UK
- Mycology Reference Centre Manchester, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Department of Infectious Diseases, Wythenshawe Hospital Manchester University NHS Foundation Trust, Manchester, UK
| | - David W Denning
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, UK
- Department of Infectious Diseases, Wythenshawe Hospital Manchester University NHS Foundation Trust, Manchester, UK
- National Aspergillosis Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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11
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Chen YT, Lee WS, Tsai CA, Fan WC, Wu PF, Wang FD. Incidence of and risk factors for cryptococcosis in kidney transplant recipients in Taiwan-A nationwide population-based study. Int J Infect Dis 2019; 88:154-158. [PMID: 31449926 DOI: 10.1016/j.ijid.2019.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/17/2019] [Accepted: 08/19/2019] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES The aim of this study was to determine the long-term incidence of cryptococcosis in kidney transplant recipients (KTRs) and to analyze its risk factors. METHODS This retrospective population-based cohort study analyzed data obtained from Taiwan's National Health Insurance Research Database for KTRs during 2000-2012 and matched cohorts. Both populations were followed until death, development of cryptococcosis, or December 2013. RESULTS A total of 4,933 KTRs and 49,930 matched patients were included. The cryptococcosis incidence rates for the KTR cohort and matched cohort were 10.59 and 0.4 per 10,000 person-years, respectively. The hazard ratio for cryptococcosis among KTRs was 26.65 (p<0.001); and 43.77 (p<0.001) for cryptococcosis affecting the central nervous system (CNS). The Kaplan-Meier method confirmed an elevated cumulative incidence of cryptococcosis among KTRs (1.00% vs. 0.04%). Predictors for cryptococcosis were advanced age (OR 1.39, 95% CI 1.02-1.89, P=0.038) and cancer (OR 2.63, 95% CI 1.22-5.67, P=0.013), but not the use of any particular class of immunosuppressants. CONCLUSIONS KTRs are at dramatically higher risk of developing cryptococcosis, especially with CNS involvement, relative to a non-KTR matched cohort. Older KTRs and those with cancer are at even higher risk of developing cryptococcosis.
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Affiliation(s)
- Yung-Tai Chen
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Nephrology, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan
| | - Wen-Sen Lee
- Division of Infectious Disease, Department of Internal Medicine, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Che-An Tsai
- Division of Infectious Disease, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wen-Chien Fan
- Divisionof Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ping-Feng Wu
- Divisionof Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Fu-Der Wang
- Divisionof Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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12
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Baddley JW, Forrest GN. Cryptococcosis in solid organ transplantation-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13543. [PMID: 30900315 DOI: 10.1111/ctr.13543] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 02/15/2019] [Accepted: 03/15/2019] [Indexed: 02/06/2023]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of cryptococcosis in the pre- and post-transplant period. The current update now includes a discussion of cryptococcosis, which is the third most common invasive fungal infection in SOT recipients. Infection often occurs a year after transplantation; however, early infections occur and donor-derived infections have been described within 3 months after transplant. There are two main species that cause infection, Cryptococcus neoformans and C gattii. Clinical onset may be insidious, but headaches, fevers, and mental status changes should warrant diagnostic testing. The lateral flow cryptococcal antigen assay is now the preferred test from serum and cerebrospinal fluid due to its rapidity, accuracy, and cost. A lumbar puncture with measurement of opening pressure is recommended for patients with suspected or proven cryptococcosis. Lipid amphotericin B plus 5-flucytosine is used as initial treatment of meningitis, disseminated infection, and moderate-to-severe pulmonary infection, followed by fluconazole as consolidation therapy. Fluconazole is effective for mild-to-moderate pulmonary infection. Immunosuppression reduction as part of management may lead to immune reconstitution syndrome that may resemble active disease.
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Affiliation(s)
- John W Baddley
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
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Sohail A, Smibert OC, Snell G, Paraskeva M, Jenney A. Cryptococcal infection in lung transplant recipients: A 5-year retrospective review at an Australian transplant center. Transpl Infect Dis 2018; 20:e12976. [PMID: 30120885 DOI: 10.1111/tid.12976] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/26/2018] [Accepted: 08/06/2018] [Indexed: 11/30/2022]
Abstract
Cryptococcosis is a common invasive fungal infection (IFI) in solid organ transplant (SOT) recipients. Little is known about cryptococcosis in lung transplant (LTx) recipients despite having one of the highest risks of infection. The aim of this study was to describe demographic and clinical features of cryptococcal infection in LTx recipients. We performed a retrospective, observational study of cryptococcal infection in LTx recipients at The Alfred Hospital in Melbourne, Australia, from 2012 to 2017. A total of 11 cases were identified. Seven patients (64%) were male and the median age was 54.7 years (range 34-69 years). Diagnosis occurred at a median of 233 days (range 1-3650 days) post-transplant. Nine patients (82%) had isolated pulmonary infection of whom 7 (78%) were asymptomatic. All were treated with oral antifungal therapy and 1 required surgical resection of infected lung. Two patients (18%) had disseminated infection; 1 with pulmonary and central nervous system (CNS) infection and 1 with isolated CNS infection. Both patients presented with headache and brain imaging demonstrated cerebral edema, myelinosis, and leptomeningeal enhancement. One of these patients died. This study highlights the fact that cryptococcal infection should remain a consideration in asymptomatic LTx recipients, especially in the presence of non-specific nodules on chest imaging, and that the presence of headache in these patients requires urgent investigation for CNS infection.
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Affiliation(s)
- Asma Sohail
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Olivia C Smibert
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Greg Snell
- Lung Transplant Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Miranda Paraskeva
- Lung Transplant Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Adam Jenney
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia.,Microbiology Unit, The Alfred Hospital, Melbourne, Victoria, Australia
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Abstract
Chronic liver disease has been associated with pulmonary dysfunction both before and after liver transplantation. Post-liver transplantation pulmonary complications can affect both morbidity and mortality often necessitating intensive care during the immediate postoperative period. The major pulmonary complications include pneumonia, pleural effusions, pulmonary edema, and atelectasis. Poor clinical outcomes have been known to be associated with age, severity of liver dysfunction, and preexisting lung disease as well as perioperative events related to fluid balance, particularly transfusion and fluid volumes. Delineating each and every one of these pulmonary complications and their associated risk factors becomes paramount in guiding specific therapeutic strategies.
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De La Cruz O, Silveira FP. Respiratory Fungal Infections in Solid Organ and Hematopoietic Stem Cell Transplantation. Clin Chest Med 2017; 38:727-739. [PMID: 29128021 DOI: 10.1016/j.ccm.2017.07.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Respiratory fungal infections are associated with high morbidity and mortality in hematopoietic stem cell (HSCT) and solid organ (SOT) transplant recipients, and are caused primarily by molds. Aspergillus is the most common pathogen. The net state of immunosuppression plays a major role in the risk of respiratory fungal infections after transplantation. Clinical presentation can be atypical and diagnosis can be delayed due to low sensitivity of diagnostic methods or inability to obtain adequate specimens. Fungal infections in HSCT and SOT carry a higher risk of dissemination. New prophylaxis strategies have changed the epidemiology of fungal infections in this patient population.
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Affiliation(s)
- Oveimar De La Cruz
- Department of Medicine, Division of Infectious Diseases, Virginia Commonwealth University, VMI Building, Suite 205, 1000 East Marshall Street, Richmond, VA 23298, USA
| | - Fernanda P Silveira
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, 3601 Fifth Avenue, Suite 3A, Pittsburgh, PA 15213, USA.
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16
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Kyriakidis I, Tragiannidis A, Zündorf I, Groll AH. Invasive fungal infections in paediatric patients treated with macromolecular immunomodulators other than tumour necrosis alpha inhibitors. Mycoses 2017; 60:493-507. [DOI: 10.1111/myc.12621] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/06/2017] [Accepted: 03/07/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Ioannis Kyriakidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Athanasios Tragiannidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Ilse Zündorf
- Institute of Pharmaceutical Biology; Goethe-University of Frankfurt; Frankfurt am Main Germany
| | - Andreas H. Groll
- Infectious Disease Research Program; Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology; University Childrens Hospital; Muenster Germany
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Abstract
Purpose of the review Cryptococcal disease is most often thought of in the context of HIV infection. Much of our knowledge of the disease originates from its management in the HIV-positive population over the last 30 years. While the majority of cases globally continue to occur in the setting of advanced HIV, Cryptococcus species is increasingly responsible for disease in HIV-negative populations including those considered normal hosts and these HIV-negative populations will be the focus of this review. Recent findings Currently available data indicated that significant differences exist in epidemiology, clinical presentation, management and outcomes of cryptococcal disease in HIV-negative populations when compared to those living with HIV. Summary Further research is required to improve our knowledge of cryptococcal disease in particular in HIV-negative cohorts so as to optimise management of the disease in the future.
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Marques S, Carmo R, Ferreira I, Bustorff M, Sampaio S, Pestana M. Cryptococcosis in Renal Transplant Recipients: A Single-Center Experience. Transplant Proc 2017; 48:2289-2293. [PMID: 27742281 DOI: 10.1016/j.transproceed.2016.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In solid organ transplant patients, 8% of invasive fungal infections are attributed to Cryptococcus. The aim of this study was to determine the frequency, risk factors, clinical characteristics, and outcome of kidney transplant recipients (TR) infected with Cryptococcus. CASE SERIES Between 2007 and 2014, a total of 500 kidney transplantations were performed at São João Hospital, in Porto, Portugal. Six infections by C. neoformans were reported, an incidence of 1.2% (3 disseminated, 2 meningeal, and 1 cutaneous). Patients were 65-72 years of age and 4 of 6 were male, compared with all kidney TR, among whom the mean age was 51.1 years and 60% were male. Three cases of crytococcosis occurred within the first 6 months after transplantation; 3 patients had cytomegalovirus infection and leukopenia, and 2 patients' immunosuppression had been increased in the last 6 months. Meningitis presented with headache, fever, and acute mental confusion; pulmonary involvement presented with respiratory insufficiency and infiltrative or nodular lung lesions; and cutaneous infections presented as cellulitis or skin abscess. Blood cultures for C. neoformans were positive in 3 cases; all of these patients had positive cryptococcal antigen of 1:128 to 1:8192. Five patients received liposomal amphotericin B for 9-21 days, followed by fluconazole. Four patients lost their grafts, and one patients died after a persistent vegetative state due to cryptococcal meningitis. CONCLUSIONS This small case series led to suspicion of an association between cryptococcosis and older age, renal dysfunction, cytomegalovirus infection, and intensification of immunosuppression after rejection episodes. In our series, cryptococcosis was associated with poor graft outcome.
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Affiliation(s)
- S Marques
- Department of Nephrology, Centro Hospitalar de São João, Alameda Prof. Hernâni Monteiro, Porto, Portugal.
| | - R Carmo
- Department of Nephrology, Centro Hospitalar de São João, Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - I Ferreira
- Department of Nephrology, Centro Hospitalar de São João, Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - M Bustorff
- Department of Nephrology, Centro Hospitalar de São João, Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - S Sampaio
- Department of Nephrology, Centro Hospitalar de São João, Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - M Pestana
- Department of Nephrology, Centro Hospitalar de São João, Alameda Prof. Hernâni Monteiro, Porto, Portugal
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Ding Y, Li P, He Q, Wei H, Wu T, Xia D, Tan M, Shi Y, Su X. The CD4 + T-lymphocyte count is an important predictor for the prognosis of cryptococcosis. Eur J Clin Microbiol Infect Dis 2016; 36:897-904. [PMID: 28035481 PMCID: PMC5395594 DOI: 10.1007/s10096-016-2880-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/14/2016] [Indexed: 12/01/2022]
Abstract
There is great heterogeneity of immunity among patients with cryptococcosis, and severe immunodeficiency can lead to negative clinical outcomes. Underlying disease is a poor surrogate for immune status and inferior in predicting an individual’s prognosis. This study was intended to determine whether T-lymphocyte subgroups would be more suitable indicators regarding the severity of infection and clinical outcomes of such patients. We retrieved clinical data on 101 patients with cryptococcosis and compared the validity of multiple parameters (underlying disease and T-lymphocyte subgroups) in predicting the severity of infection and clinical outcome in these patients. For patients with CD4+ T-lymphocyte counts lower than 400/μL, the odds ratio of disseminated cryptococcosis was 23.3 (P = 0.005). There was a moderate negative correlation between CD4+ T-cell count and Apache II score (−0.609, P < 0.001). Mortality among patients with low levels of CD4+ T lymphocytes was significantly higher than among those with normal levels (23.8% vs 5.3%, P = 0.016). However, the difference was not significant if the patients were grouped by underlying disease (P = 0.067). The CD4+ T-lymphocyte count in peripheral blood is a simple and more accurate biomarker for predicting severity of infection and clinical outcome in patients with cryptococcosis.
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Affiliation(s)
- Y Ding
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China, 210002
| | - P Li
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China, 210002
| | - Q He
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Southern Medical University, Nanjing, China, 210002
| | - H Wei
- Department of Infectious Disease, Nanjing Second Hospital, Nanjing, China, 210002
| | - T Wu
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China, 210002
| | - D Xia
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China, 210002
| | - M Tan
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China, 210002
| | - Y Shi
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China, 210002
| | - X Su
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China, 210002.
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20
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Samanta P, Singh N. Complications of invasive mycoses in organ transplant recipients. Expert Rev Anti Infect Ther 2016; 14:1195-1202. [PMID: 27690694 DOI: 10.1080/14787210.2016.1242412] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Opportunistic mycoses remain a significant complication in organ recipients. Areas covered: This review is an evidence-based presentation of current state-of-knowledge and our perspective on recent developments in the field Expert commentary: Invasive fungal infections are associated with reduced allograft and patient survival, increase in healthcare resource utilization, and newly appreciated but largely unrecognized immunologic sequelae, such as immune reconstitution syndrome. Given adverse outcomes associated with established infections, prophylaxis is a widely used strategy for the prevention of these infections. Currently available biomarkers that detect circulating fungal cell wall constituents i.e., galactomannan and 1, 3-β-D-glucan have not proven to be beneficial as screening tools for employing targeted prophylaxis or as diagnostic assays in this patient population. However, subsets of patients at risk for opportunistic fungal infections can be identified based on clinically identifiable characteristics or events. Preventive strategies targeted towards these patients are a rational approach for optimizing outcomes.
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Affiliation(s)
- Palash Samanta
- a Division of Infectious Diseases , University of Pittsburgh , Pittsburgh , PA , USA
| | - Nina Singh
- b Division of Infectious Diseases , University of Pittsburgh and VA Pittsburgh Medical Center , Pittsburgh , PA , USA
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21
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Claustre J, Brion JP, Quétant S, Bedouch P, Pison C, Camara B. Favorable Evolution of Cryptococcal Meningitis in the Context of Flucytosine Resistance. EXP CLIN TRANSPLANT 2016; 16:110-113. [PMID: 27143150 DOI: 10.6002/ect.2015.0217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cryptococcal meningitis is a critical illness affecting 0.2% to 5% solid-organ transplant recipients with a 40% to 50% mortality. We report the case of a 48-year-old lung transplant recipient, who, 15 months after a right lung graft, kept parakeets and developed meningitis due to Cryptococcus neoformans. Immunosuppressive treatment was based on a quadruple sequential immunosuppressive therapy that included induction therapy with thymoglobulin, followed by corticosteroids, calcineurin inhibitors, and mycophenolate mofetil. Antifungal susceptibility testing of Cryptococcus neoformans showed resistance to flucytosine and intermediate sensitivity to fluconazole. Initial treatment adhered to international guidelines; however, the patient could not tolerate an effective double-antifungal therapy during the first 2 months of treatment. Despite this delayed treatment for an aggressive infection in an immunocompromised patient, the patient survived without relapse and received maintenance treatment with fluconazole during the course of 3 years. Administration of calcineurin inhibitors as immunosuppressive treatment may partly explain this outcome, as this therapeutic class is known to protect from severe forms of cryptococcal meningitis.
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Affiliation(s)
- Johanna Claustre
- From the Department of Biochemistry, Molecular and Cellular Biology, Georgetown University Medical Center, Washington DC 20007, USA
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22
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Anesi JA, Baddley JW. Approach to the Solid Organ Transplant Patient with Suspected Fungal Infection. Infect Dis Clin North Am 2015; 30:277-96. [PMID: 26739603 DOI: 10.1016/j.idc.2015.10.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
In solid organ transplant (SOT) recipients, invasive fungal infections (IFIs) are associated with significant morbidity and mortality. Detection of IFIs can be difficult because the signs and symptoms are similar to those of viral or bacterial infections, and diagnostic techniques have limited sensitivity and specificity. Clinicians must rely on knowledge of the patient's risk factors for fungal infection to make a diagnosis. The authors describe their approach to the SOT recipient with suspected fungal infection. The epidemiology of IFIs in the SOT population is reviewed, and a syndromic approach to suspected IFI in SOT recipients is described.
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Affiliation(s)
- Judith A Anesi
- Division of Infectious Diseases, University of Pennsylvania, 3400 Spruce Street, 3 Silverstein, Suite E, Philadelphia, PA 19104, USA
| | - John W Baddley
- Department of Medicine, University of Alabama at Birmingham, 1900 University Boulevard, 229 THT, Birmingham, AL 35294, USA; Medical Service, Birmingham VA Medical Center, 700 South 19th street, Birmingham, AL 35233, USA.
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23
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Cryptococcosis in Patients With Cirrhosis of the Liver and Posttransplant Outcomes. Transplantation 2015; 99:2132-41. [DOI: 10.1097/tp.0000000000000690] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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24
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Helfrich M, Ison M. Opportunistic infections complicating solid organ transplantation with alemtuzumab induction. Transpl Infect Dis 2015; 17:627-36. [DOI: 10.1111/tid.12428] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 04/26/2015] [Accepted: 07/17/2015] [Indexed: 12/12/2022]
Affiliation(s)
- M. Helfrich
- Northwestern University Transplant Outcomes Research Collaborative; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
| | - M.G. Ison
- Northwestern University Transplant Outcomes Research Collaborative; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
- Divisions of Infectious Diseases & Organ Transplantation; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
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25
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Fungal infections in intestinal and multivisceral transplant recipients. Curr Opin Organ Transplant 2015; 20:295-302. [DOI: 10.1097/mot.0000000000000188] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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26
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MacEwen CR, Ryan A, Winearls CG. Donor transmission of Cryptococcus neoformans presenting late after renal transplantation. Clin Kidney J 2015; 6:224-7. [PMID: 26019853 PMCID: PMC4432446 DOI: 10.1093/ckj/sft006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 01/09/2013] [Indexed: 12/19/2022] Open
Affiliation(s)
- Clare R MacEwen
- The Oxford Kidney Unit , Oxford University Hospitals NHS Trust , Oxford OX3 7LE , UK
| | - Aidan Ryan
- The Oxford Kidney Unit , Oxford University Hospitals NHS Trust , Oxford OX3 7LE , UK
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27
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Henn A, Mellon G, Henry B, Roos-Weil D, Jauréguiberry S, Mordant P, Fekkar A, Caumes E. Disseminated cryptococcosis, invasive aspergillosis, and mucormycosis in a patient treated with alemtuzumab for chronic lymphocytic leukaemia. ACTA ACUST UNITED AC 2014; 46:231-4. [DOI: 10.3109/00365548.2013.866269] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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28
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Pruitt AA, Graus F, Rosenfeld MR. Neurological complications of solid organ transplantation. Neurohospitalist 2013; 3:152-66. [PMID: 24167649 DOI: 10.1177/1941874412466090] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Solid organ transplantation (SOT) is the preferred treatment for an expanding range of conditions whose successful therapy has produced a growing population of chronically immunosuppressed patients with potential neurological problems. While the spectrum of neurological complications varies with the type of organ transplanted, the indication for the procedure, and the intensity of long-term required immunosuppression, major neurological complications occur with all SOT types. The second part of this 2-part article on transplantation neurology reviews central and peripheral nervous system problems associated with SOT with clinical and neuroimaging examples from the authors' institutional experience. Particular emphasis is given to conditions acquired from the donated organ or tissue, problems specific to types of organs transplanted and drug therapy-related complications likely to be encountered by hospitalists. Neurologically important syndromes such as immune reconstitution inflammatory syndrome (IRIS), posterior reversible encephalopathy syndrome (PRES), and posttransplantation lymphoproliferative disorder (PTLD) are readdressed in the context of SOT.
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Affiliation(s)
- Amy A Pruitt
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
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29
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Gaona-Flores VA. Central nervous system and Cryptococcus neoformans. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2013; 5:492-3. [PMID: 24083226 PMCID: PMC3784928 DOI: 10.4103/1947-2714.117321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Veronica A Gaona-Flores
- Infectology Hospital, National Medical Center "La Raza" Instituto Mexicano del Seguro Social, México, D.F., Mexico
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30
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Abstract
PURPOSE OF REVIEW Hematopoietic stem cell as well as solid-organ transplantation is being carried out with increasing frequency throughout the world. Lower respiratory tract infections (LRTIs) remain a common life-threatening complication faced by the transplant recipients. The purpose of this review is to provide up-to-date information on pulmonary infections among the transplant recipients, especially emphasizing the endemicity of microorganisms, epidemiology, work-up of infections, and principles of their management. RECENT FINDINGS A lower respiratory tract infection such as pneumonia is the most frequent of all the infections and is associated with high morbidity and mortality. Factors increasing the risk of pulmonary infections include surgical techniques, immune status, chemoradiotherapy, alloimmune mechanisms between the host and the graft, and the environment. A high degree of suspicion, computed tomography (CT) scan of the chest, and flexible bronchoscopy are required in most to establish the diagnosis. SUMMARY Proper management of LRTI in transplant recipients requires a high degree of suspicion, thorough knowledge of the epidemiology and endemicity of the suspected organisms, CT scan of the chest, and expertise at bronchoscopy. Utmost teamwork among transplant physicians, infectious disease specialist, and bronchoscopist is essential.
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31
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Baddley JW, Forrest GN. Cryptococcosis in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:242-9. [PMID: 23465017 DOI: 10.1111/ajt.12116] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- J W Baddley
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
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32
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Singh N, Huprikar S, Burdette SD, Morris MI, Blair JE, Wheat LJ. Donor-derived fungal infections in organ transplant recipients: guidelines of the American Society of Transplantation, infectious diseases community of practice. Am J Transplant 2012; 12:2414-28. [PMID: 22694672 DOI: 10.1111/j.1600-6143.2012.04100.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Donor-derived fungal infections can be associated with serious complications in transplant recipients. Most cases of donor-derived candidiasis have occurred in kidney transplant recipients in whom contaminated preservation fluid is a commonly proposed source. Donors with cryptococcal disease, including those with unrecognized cryptococcal meningoencephalitis may transmit the infection with the allograft. Active histoplasmosis or undiagnosed and presumably asymptomatic infection in the donor that had not resolved by the time of death can result in donor-derived histoplasmosis in the recipient. Potential donors from an endemic area with either active or occult infection can also transmit coccidioidomycosis. Rare instances of aspergillosis and other mycoses, including agents of mucormycosis may also be transmitted from infected donors. Appropriate diagnostic evaluation and prompt initiation of appropriate antifungal therapy are warranted if donor-derived fungal infections are a consideration. This document discusses the characteristics, evaluation and approach to the management of donor-derived fungal infections in organ transplant recipients.
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Affiliation(s)
- N Singh
- University of Pittsburgh, PA, USA.
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33
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Shoham S, Marr KA. Invasive fungal infections in solid organ transplant recipients. Future Microbiol 2012; 7:639-55. [PMID: 22568718 DOI: 10.2217/fmb.12.28] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Invasive fungal infections are a major problem in solid organ transplant (SOT) recipients. Overall, the most common fungal infection in SOT is candidiasis, followed by aspergillosis and cryptococcosis, except in lung transplant recipients, where aspergillosis is most common. Development of invasive disease hinges on the interplay between host factors (e.g., integrity of anatomical barriers, innate and acquired immunity) and fungal factors (e.g., exposure, virulence and resistance to prophylaxis). In this article, we describe the epidemiology and clinical features of the most common fungal infections in organ transplantation. Within this context, we review recent advances in diagnostic modalities and antifungal chemotherapy, and their impact on evolving prophylaxis and treatment paradigms.
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Affiliation(s)
- Shmuel Shoham
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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34
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Abstract
Cryptococcosis is a significant opportunistic mycoses in organ transplant recipients. Topical developments in the field in the past few years have highlighted important issues and at the same time raised new questions regarding the management of this yeast. These include, for example, management of pretransplant cryptococcosis during transplant candidacy and timing of transplant in these instances; potential for donor transmission of cryptococcosis in light of recent fatal transmissions; and prevention and treatment of Cryptococcus-associated immune reconstitution syndrome. Discussed herein are challenges posed by these issues and evidence-based data to optimize the management of posttransplant cryptococcosis.
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35
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Getts DR, Shankar S, Chastain EML, Martin A, Getts MT, Wood K, Miller SD. Current landscape for T-cell targeting in autoimmunity and transplantation. Immunotherapy 2012; 3:853-70. [PMID: 21751954 DOI: 10.2217/imt.11.61] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
In recent years, substantial advances in T-cell immunosuppressive strategies and their translation to routine clinical practice have revolutionized management and outcomes in autoimmune disease and solid organ transplantation. More than 80 diseases have been considered to have an autoimmune etiology, such that autoimmune-associated morbidity and mortality rank as third highest in developed countries, after cardiovascular diseases and cancer. Solid organ transplantation has become the therapy of choice for many end-stage organ diseases. Short-term outcomes such as patient and allograft survival at 1 year, acute rejection rates, as well as time course of disease progression and symptom control have steadily improved. However, despite the use of newer immunosuppressive drug combinations, improvements in long-term allograft survival and complete resolution of autoimmunity remain elusive. In addition, the chronic use of nonspecifically targeted immunosuppressive drugs is associated with significant adverse effects and increased morbidity and mortality. In this article, we discuss the current clinical tools for immune suppression and attempts to induce long-term T-cell tolerance induction as well as much-needed future approaches to produce more short-acting, antigen-specific agents, which may optimize outcomes in the clinic.
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Affiliation(s)
- Daniel R Getts
- Tolera Therapeutics Inc, 350 E Michigan Ave Ste 205, Kalamazoo, MI 49007, USA.
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36
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Qureshi ZA, Kwak EJ, Nguyen MH, Silveira FP. Ochroconis gallopava: a dematiaceous mold causing infections in transplant recipients. Clin Transplant 2011; 26:E17-23. [DOI: 10.1111/j.1399-0012.2011.01528.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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37
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Islam A, Mody CH. Management of fungal lung disease in the immunocompromised. Ther Adv Respir Dis 2011; 5:305-24. [PMID: 21807757 DOI: 10.1177/1753465811398720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pulmonary mycoses are among the most feared infections encountered in immunocompromised patients. The problem is amplified by the increasing numbers of chronically immunocompromised patients that have substantially increased both the prevalence and clinical severity of infections caused by fungi. Moreover, fungal infections in this patient population pose challenges in diagnosis and management. Fortunately, recent advances in diagnostics and antifungal therapy, and their direct application to specific diseases, provide important new approaches to this complex and often seriously ill patient population. In this article we review the commonly occurring pulmonary fungal infections in the immunocompromised population with a particular focus on their management.
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Affiliation(s)
- Anowara Islam
- Snyder Institute for Infection, Inflammation and Immunity, University of Calgary, Alberta, Canada
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Levitsky J, Thudi K, Ison MG, Wang E, Abecassis M. Alemtuzumab induction in non-hepatitis C positive liver transplant recipients. Liver Transpl 2011; 17:32-7. [PMID: 21254342 DOI: 10.1002/lt.22180] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Limited data exist for the use of alemtuzumab (AL) induction in liver transplantation (LT) recipients. We compared the outcomes of hepatitis C virus-negative LT recipients who received AL induction followed by tacrolimus and mycophenolate mofetil without steroids to cohort who received no AL induction, tacrolimus, and a steroid taper. Fifty-five AL-induced recipients were compared to 85 non-AL-induced recipients with similar characteristics. Two-year patient survival (80% versus 88.2%, P = 0.0665) and graft survival (76.4% versus 82.4%, P = 0.1792) were not significantly different between the AL and non-AL groups, respectively. Other outcomes, including acute rejection (20% versus 30.3%), renal dysfunction (creatinine levels: 1.3 ± 0.3 versus 1.4 ± 0.6 mg/dL), and immunosuppressant monotherapy (29.1% versus 44.3%), were not significantly different between the AL and non-AL groups, respectively (P > 0.05). The number of rejection episodes (12 versus 42, P = 0.02) and the number of patients with new-onset hypertension (3 versus 15, P = 0.03) were lower in the AL group, although the incidence of all posttransplant infections was higher with AL (63.6% versus 44.3%, P = 0.03), primarily because of an increase in viral infections. In conclusion, a steroid-free AL induction regimen was associated with less hypertension and rejection but with more infectious complications; thus, the overall benefit of AL induction in LT recipients is called into question.
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Affiliation(s)
- Josh Levitsky
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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Sifri CD, Sun HY, Cacciarelli TV, Wispelwey B, Pruett TL, Singh N. Pretransplant cryptococcosis and outcome after liver transplantation. Liver Transpl 2010; 16:499-502. [PMID: 20373460 DOI: 10.1002/lt.22024] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The posttransplant outcomes and optimal management of patients with end-stage liver disease who develop cryptococcosis prior to transplantation have not been defined. We discuss these issues in the context of successful liver transplantation and pretransplant cryptococcal disease. Our report suggests that liver transplantation may be cautiously considered under the umbrella of fluconazole therapy in patients with end-stage liver disease and pretransplant cryptococcosis, provided that disease control is achieved with adequate treatment before transplantation.
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Infections after the use of alemtuzumab in solid organ transplant recipients: a comparative study. Diagn Microbiol Infect Dis 2010; 66:7-15. [DOI: 10.1016/j.diagmicrobio.2009.08.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2007] [Revised: 08/16/2009] [Accepted: 08/20/2009] [Indexed: 11/20/2022]
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Affiliation(s)
- N Singh
- VA Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, PA, USA. nis5+@pitt.edu
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Abstract
PURPOSE OF REVIEW Liver transplantation has always been fraught with conflict. The ongoing shortage of organs for transplantation has led to sicker recipients and the pressure to utilize more marginal grafts. At the same time, increasing public scrutiny and regulatory oversight have emphasized lower costs and better outcomes. This environment exaggerates the importance of the most fundamental conflict: that between preventing allograft rejection and avoiding the toxicities of immunosuppressive agents and the risks of infection. Resolving this struggle requires skillful balancing and a need to keep abreast of the latest developments. Alemtuzumab is a still-new agent with relatively little clinical experience that, therefore, deserves a review and an update of current knowledge in the setting of liver transplantation. RECENT FINDINGS The use of alemtuzumab in liver transplant recipients has shown promise with little information to support concerns over significantly increased risks of infectious complications. However, there have been very few studies overall and fewer still in the last 2-3 years. Much of what is known must still be extrapolated from experience in kidney transplant recipients. SUMMARY Alemtuzumab appears to be a drug with significant potential advantages for liver transplant recipients. Improved renal function may be the largest potential advantage. However, the advantages may be offset in some groups. Defining subgroups will be critical to the definition of the optimal role of alemtuzumab in liver transplant recipients.
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Abstract
Cryptococcosis occurs in immunocompromised and, in special cases, immunocompetent individuals. There have been a number of important advances in the field, but, despite current treatment, patients continue to die of the infection. This article reviews cryptococcosis epidemiology, clinical features, and management. Current knowledge is incomplete, however, so this article also discusses some of the gaps in the present understanding of cryptococcosis. The hope is that current research striving to understand the mechanisms of host evasion of Cryptococcus will result in improved treatment regimens that decrease both the mortality and morbidity of cryptococcosis.
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Affiliation(s)
- Shaunna M Huston
- Department of Medical Science, University of Calgary, Alberta, Canada
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Bassetti M, Repetto E, Mikulska M, Miglino M, Clavio M, Gobbi M, Righi E, Viscoli C. Cryptococcus neoformans fatal sepsis in a chronic lymphocytic leukemia patient treated with alemtuzumab: case report and review of the literature. J Chemother 2009; 21:211-4. [PMID: 19423476 DOI: 10.1179/joc.2009.21.2.211] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Cryptococcosis is a disseminated fungal disease typically associated with immunosuppression and characterized by high mortality rates. Cryptococcus neoformans has been reported to be isolated from blood cultures in around 20% of patients with cryptococcosis, and cryptococcemia has been correlated with poor prognosis. We report a case of fatal C. neoformans fungemia in a neutropenic patient with a history of chronic lymphocytic leukemia treated with alemtuzumab. The patient presented with loss of consciousness and died after 5 days of antifungal therapy with liposomal amphotericin B. The international literature regarding opportunistic infections after immunosuppressive therapy with alemtuzumab with particular attention on fungal infections has also been reviewed.
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Affiliation(s)
- M Bassetti
- Infectious Diseases Division, S. Martino Hospital, University of Genoa, Genoa, Italy.
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Abstract
PURPOSE OF REVIEW Cryptococcosis is an important opportunistic fungal infection, especially in the immunocompromised patient. Meningitis is the most common manifestation of cryptococcosis; however, cryptococcal lung disease is probably underdiagnosed, and knowledge of epidemiology, diagnosis, and treatment is necessary. RECENT FINDINGS Cryptococcal lung disease ranges from asymptomatic colonization or infection to severe pneumonia with respiratory failure. Clinical presentation of pulmonary cryptococcosis is highly variable and often is related to the immune status of the patient. There have been many important clinical trials outlining treatment of cryptococcal meningitis in patients with AIDS, but there is a lack of treatment data available for patients with cryptococcal lung disease. Treatment recommendations for cryptococcal lung disease are made on the basis of host immune status and severity of clinical illness. For less severe disease, fluconazole therapy is recommended. In immunocompromised patients, or those with severe disease, induction therapy with an amphotericin B preparation and flucytosine, followed by fluconazole as consolidation and maintenance therapy, is recommended. SUMMARY Cryptococcal lung disease is an important and probably underdiagnosed infection. Knowledge of the epidemiology, diagnostic methodologies, and treatment is needed to ensure good patient outcomes.
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Abstract
PURPOSE OF REVIEW Lung transplant's Achilles heel is chronic rejection. This is the reason why high immunosuppression is used, which leads to the development of infections. Fungal infections are a great obstacle in lung transplant patients' progress, not only because of their impact on patient survival, but also because fungal infections indirectly have an influence on the graft's progress. This review highlights the changing spectrum of invasive fungal infections as well as the most recent developments in diagnosis, prophylaxis, treatment and monitoring of lung transplantation. RECENT FINDINGS Fungal infections have a bimodal presentation: early onset, in relation to difficult postsurgeries and prior colonizations, and late onset, primarily in relation to chronic rejection and terminal renal insufficiency. The clinical impact of non-Aspergillus moulds is still unknown. Recent efforts have focused on nonculture-based methods to establish a rapid diagnosis. However, multicentre studies are needed to establish the diagnostic value of galactomannan antigen assay in invasive aspergillosis in lung transplantation. In addition, studies of the sensitivity and specificity of PCR assays are required to establish their diagnostic value. Unfortunately, only some advances in the diagnosis of aspergillosis have been achieved. SUMMARY Prophylaxis should be tailored according to the different individual patient's risk status. Combined treatments, including surgical therapy, may be useful in some patients.
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Peleg AY, Lasalvia MT, Mylonakis E, Silveira FP. Prophylaxis against pulmonary viral and fungal infections in solid organ transplant recipients. Curr Infect Dis Rep 2009; 11:209-15. [PMID: 19366563 PMCID: PMC7089285 DOI: 10.1007/s11908-009-0031-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pulmonary viral and fungal infections in solid organ transplant recipients are one of the most common and potentially life-threatening infections. Understanding the strategies used for prophylaxis and prevention of these infections is critical for the health and well-being of transplant recipients. Prophylactic measures range from simple patient education to complex chemoprophylactic interventions; however, a multifaceted approach is most often required. This article focuses on strategies to prevent pulmonary viral and fungal infections in transplant recipients, with an emphasis on recent evidence that may influence practice guidelines.
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Affiliation(s)
- Anton Y Peleg
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Massachusetts General Hospital, and Harvard Medical School, 110 Francis Street, LMOB Suite GB, Boston, MA 02215, USA.
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Farkas SA, Schnitzbauer AA, Kirchner G, Obed A, Banas B, Schlitt HJ. Calcineurin inhibitor minimization protocols in liver transplantation. Transpl Int 2009; 22:49-60. [PMID: 19121146 DOI: 10.1111/j.1432-2277.2008.00796.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Liver transplant recipients are at increasingly high risk for suffering from impaired renal function and probable need of renal replacement therapy. Extended criteria organs and transplantation of patients with higher model for end-stage liver disease scores further increase this problem. Acute and chronic nephrotoxicity are the trade-off in immunosuppression with potent calcineurin inhibitors (CNIs). As a good renal function is associated with better graft and patient survival, CNI minimization protocols have been developed. Current strategies to overcome CNI toxicity include reduction or withdrawal of CNIs concurrently with switching over to mammalian target of rapamycin inhibitor or mycophenolate mofetil (MMF)-based regimens. This strategy caused an improvement in renal function in a significant number of liver transplantation patients according to several studies. However, total CNI avoidance seems to result in higher rejection rates. To prevent chronic renal dysfunction in patients prone to or with acute renal failure, CNI delay - with induction therapy for bridging - followed by low-dose CNI in combination with MMF are proven strategies without risking higher rejection rates. An individualized, tailor-made immunosuppressive regime, with a special focus on renal function is recommended. This review gave an overview on CNI minimization protocols in liver transplantation also focusing on recently analyzed studies.
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Affiliation(s)
- Stefan A Farkas
- Department of Surgery, University Hospital Regensburg, Germany.
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Abstract
PURPOSE OF REVIEW Expanding access to antiretroviral treatment has dramatically improved the long-term prognosis of patients with HIV-associated cryptococcal disease who survive the acute infection. However, the incidence and acute mortality of HIV-associated cryptococcal meningitis remain high. In this context, this review summarizes urgently needed recent work aimed at improving the acute management of cryptococcal infection in immunocompromised hosts. RECENT FINDINGS Studies have started to optimize antifungal regimens and address the complications of raised cerebrospinal fluid pressure and cryptococcal immune reconstitution syndrome. Amphotericin B at 1 mg/kg per day has been shown to be more rapidly fungicidal than the standard dose of 0.7 mg/kg per day, and new data support the importance of combination therapy with flucytosine. Amphotericin B and fluconazole at 800 mg is an alternative combination that appears superior to amphotericin B alone. At a dosage of 400 mg per day, fluconazole alone is much less rapidly fungicidal than amphotericin B and is associated with the development of secondary resistance. SUMMARY Recent findings support the use of rapidly fungicidal initial antifungal therapy with amphotericin B-based combination treatment. Where amphotericin B treatment is not yet feasible, studies are needed to optimize oral regimens. Based on accumulating data on rate of clearance of infection, the most promising new regimens in terms of fungicidal activity and safety could be selected for clinical endpoint trials.
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