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Haque E, Muhsen IN, Rasheed W, Fakih RE, Aljurf M. Parasitic infections in hematopoietic stem cell transplant recipients. Transpl Infect Dis 2023; 25 Suppl 1:e14160. [PMID: 37793057 DOI: 10.1111/tid.14160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 09/16/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION Hematopoietic stem cell transplantation (HSCT) is a vital treatment for various hematological disorders. However, HSCT recipients face increased risks of infectious complications due to immunosuppression. Parasitic infections are a significant concern in this vulnerable population and can lead to substantial morbidity and mortality. This review examines parasitic infections in HSCT recipients, focusing on major infections affecting different organ systems, including intestinal parasites (Giardia spp., Entamoeba histolytica, and Cryptosporidium spp.), hematologic parasites (Plasmodium spp. and Babesia spp.), and tissue/visceral parasites (Toxoplasma gondii, Leishmania spp., and Trypanosoma cruzi). METHODS A systematic search of relevant literature was conducted and included studies up to August 2023. Databases included PubMed, Google Scholar, were queried using specific keywords related to parasitic infections in HSCT patients. The epidemiology, risk factors, clinical presentation, diagnostic methods, and treatment approaches for each infection were evaluated. RESULTS AND CONCLUSION Knowing the epidemiology, risk factors, and clinical presentations are crucial for timely intervention and successful management. By emphasizing early detection, effective therapies, and the unique challenges posed by each of these infections, this review highlights the importance of tailored strategies for HSCT recipients. Future research can further refine management protocols to enhance care and outcomes for these patients.
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Affiliation(s)
- Emaan Haque
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Ibrahim N Muhsen
- Department of Medicine, Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Walid Rasheed
- Department of Adult Hematology and Stem Cell Transplant, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Riad El Fakih
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Adult Hematology and Stem Cell Transplant, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mahmoud Aljurf
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Adult Hematology and Stem Cell Transplant, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Muhsen IN, Galeano S, Niederwieser D, Koh MBC, Ljungman P, Machado CM, Kharfan-Dabaja MA, de la Camara R, Kodera Y, Szer J, Rasheed W, Cesaro S, Hashmi SK, Seber A, Atsuta Y, Saleh MFM, Srivastava A, Styczynski J, Alrajhi A, Almaghrabi R, Abid MB, Chemaly RF, Gergis U, Brissot E, El Fakih R, Riches M, Mikulska M, Worel N, Weisdorf D, Greinix H, Cordonnier C, Aljurf M. Endemic or regionally limited parasitic and fungal infections in haematopoietic stem-cell transplantation recipients: a Worldwide Network for Blood and Marrow Transplantation (WBMT) Review. THE LANCET HAEMATOLOGY 2023; 10:e295-e305. [PMID: 36990624 DOI: 10.1016/s2352-3026(23)00031-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 11/17/2022] [Accepted: 01/18/2023] [Indexed: 03/29/2023]
Abstract
There is a scarcity of data on endemic and regionally limited fungal and parasitic infections in recipients of haematopoietic stem-cell transplantation (HSCT) outside western Europe and North America. This Worldwide Network for Blood and Marrow Transplantation (WBMT) Review is one of two papers aiming to provide guidance to transplantation centres worldwide regarding prevention, diagnosis, and treatment based on the currently available evidence and expert opinion. These recommendations were created and reviewed by physicians with expertise in HSCT or infectious disease, representing several infectious disease and HSCT groups and societies. In this paper, we review the literature on several endemic and regionally limited parasitic and fungal infections, some of which are listed as neglected tropical diseases by WHO, including visceral leishmaniasis, Chagas disease, strongyloidiasis, malaria, schistosomiasis, histoplasmosis, blastomycosis, and coccidioidomycosis.
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Affiliation(s)
- Ibrahim N Muhsen
- Section of Hematology and Oncology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | | | - Dietger Niederwieser
- Division of Hematology and Medical Oncology, University of Leipzig, Leipzig, Germany; Lithuanian University of Health Sciences Kauno Klinikos, Lithuania; Aichi Medical University School of Medicine, Nagakute, Japan
| | - Mickey B C Koh
- Infection and Immunity Clinical Academic Group, University of London and Department of Haematology, St George's Hospital and Medical School, London, UK; Cell Therapy Facility, Blood Services Group, Health Sciences Authority, Singapore
| | - Per Ljungman
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital Huddinge, Karolinska Comprehensive Cancer Center, Stockholm, Sweden; Division of Hematology, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Clarisse M Machado
- Virology Laboratory Institute of Tropical Medicine-University of São Paulo Medical School, São Paulo, Brazil; HCT Program - Hospital Amaral Carvalho, Jahu, Brazil
| | | | | | - Yoshihisa Kodera
- Center for Hematopoietic Stem Cell Transplantation, Aichi Medical University Hospital, Nagakute, Japan
| | - Jeff Szer
- Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Walid Rasheed
- Adult Hematology and Stem Cell Transplant, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Simone Cesaro
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Shahrukh K Hashmi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Department of Medicine, Sheikh Shakbout Medical City, Abu Dhabi, United Arab Emirates; College of Medicine & Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Adriana Seber
- Hospital Samaritano Higienópolis and Graacc - Unifesp, São Paulo, Brazil
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagakute, Japan; Department of Registry Science for Transplant and Cellular Therapy, Nagakute, Japan
| | - Mostafa F Mohammed Saleh
- Adult Hematology and Stem Cell Transplant, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Alok Srivastava
- Department of Hematology, Christian Medical College, Vellore, India; Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - Abdulrahman Alrajhi
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Reem Almaghrabi
- Organ Transplantation Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Muhammad Bilal Abid
- Division of Divisions of Hematology/Oncology & Infectious Diseases, BMT & Cellular Therapy Program, Milwaukee, WI, USA
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Usama Gergis
- Sidney Kimmel Cancer Center, Philadelphia, PA, USA
| | - Eolia Brissot
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Riad El Fakih
- Adult Hematology and Stem Cell Transplant, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Marcie Riches
- Division of Hematology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Malgorzata Mikulska
- Division of Infectious Diseases, DISSAL, University of Genova, Italy and IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Nina Worel
- Department of Transfusion Medicine and Cell Therapy, Medical University of Vienna, Vienna, Austria
| | - Daniel Weisdorf
- Division of Hematology, Oncology and Transplantation, University of Minnesota, MN, USA
| | | | - Catherine Cordonnier
- Haematology Department, Henri Mondor Hospital and University Paris-Est-Créteil, Créteil, France
| | - Mahmoud Aljurf
- Adult Hematology and Stem Cell Transplant, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
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Presence of anti-Leishmania antibodies in candidates for kidney transplantation. Int J Infect Dis 2020; 98:470-477. [PMID: 32645376 DOI: 10.1016/j.ijid.2020.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Visceral leishmaniasis (VL) is a progressive disease that, left untreated, is typically fatal. The purpose of this investigation was to detect Leishmania sp. infection in hemodialysis patients who had received multiple blood transfusions at a private clinic in Campo Grande, Mato Grosso do Sul state, Midwest Brazil. METHODS Fifty randomly selected volunteers were interviewed for collection of demographic, socioeconomic, and epidemiological data. Indirect immunofluorescence (titers positive when ≥1:40) and rK39 immunochromatographic tests were employed for serological investigation. RESULTS Males predominated (60%). Age ranged from 20 to 77 years. Most subjects reported being on hemodialysis for at least one year (94%) and 84% were candidates for kidney transplantation, 67% of whom were on the waiting list. Leishmania sp. infection was detected in 32%. Contact with infected dogs was the only variable associated with infection. CONCLUSIONS Under immunocompromised conditions, VL is opportunistic and potentially fatal. Despite existing risks, screening for VL is not performed in asymptomatic donors and recipients. The detection of anti-Leishmania antibodies in these patients reinforces the need for infection screening before immunosuppressive treatment is initiated to reduce not only the risks of VL development and severity, but also mortality rates in cases of reactivation of latent infection.
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Peixoto D, Prestes DP. Parasitic Infections of the Stem Cell Transplant Recipient and the Hematologic Malignancy Patient, Including Toxoplasmosis and Strongyloidiasis. Infect Dis Clin North Am 2019; 33:567-591. [PMID: 31005139 DOI: 10.1016/j.idc.2019.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) recipients may infrequently develop parasitic infections at the time of the procedure via contamination from allograft tissue or blood products, and in the post-transplantation period through the traditional route of infection or as a reactivation caused by immunosuppression related to the transplant. To reduce risk, efforts should be directed at performing a comprehensive history, maintaining a high index of suspicion, and adhering to preventive measures. Additional strategies for the prevention, screening and careful follow-up, identification, and pre-emptive treatment of parasitic infections are required to reduce morbidity and mortality in HSCT patients.
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Affiliation(s)
- Driele Peixoto
- São Paulo State Cancer Institute (ICESP), Hospital das Clínicas, Av. Dr. Arnaldo, 251, São Paulo CEP: 01246-000, Brazil.
| | - Daniel P Prestes
- A. C. Camargo Cancer Center, Rua Professor Antonio Prudente, 211, Sao Paulo CEP: 01509-010, Brazil; Emilio Ribas Infectious Diseases Institute, Av. Doutor Arnaldo, 165, Sao Paulo CEP: 01246-900, Brazil
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Matthews H, Noulin F. Unexpected encounter of the parasitic kind. World J Stem Cells 2019; 11:904-919. [PMID: 31768219 PMCID: PMC6851008 DOI: 10.4252/wjsc.v11.i11.904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 08/10/2019] [Accepted: 09/13/2019] [Indexed: 02/06/2023] Open
Abstract
Both parasitology and stem cell research are important disciplines in their own right. Parasites are a real threat to human health causing a broad spectrum of diseases and significant annual rates morbidity and mortality globally. Stem cell research, on the other hand, focuses on the potential for regenerative medicine for a range of diseases including cancer and regenerative therapies. Though these two topics might appear distant, there are some “unexpected encounters”. In this review, we summarise the various links between parasites and stem cells. First, we discuss how parasites’ own stem cells represent interesting models of regeneration that can be translated to human stem cell regeneration. Second, we explore the interactions between parasites and host stem cells during the course of infection. Third, we investigate from a clinical perspective, how stem cell regeneration can be exploited to help circumvent the damage induced by parasitic infection and its potential to serve as treatment options for parasitic diseases in the future. Finally, we discuss the importance of screening for pathogens during organ transplantation by presenting some clinical cases of parasitic infection following stem cell therapy.
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Affiliation(s)
- Holly Matthews
- Centre for Applied Entomology and Parasitology, School of Life Sciences, Keele University, Keele ST5 5BG, United Kingdom
| | - Florian Noulin
- Centre for Applied Entomology and Parasitology, School of Life Sciences, Keele University, Keele ST5 5BG, United Kingdom
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Visceral leishmaniasis in hematopoietic cell transplantation: Case report and review of the literature. J Infect Chemother 2018; 24:990-994. [PMID: 30098915 DOI: 10.1016/j.jiac.2018.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/24/2018] [Accepted: 05/28/2018] [Indexed: 02/03/2023]
Abstract
Visceral leishmaniasis has been recognized as an opportunistic infection affecting people with cellular-immunity impairment, including hematopoietic cell transplantation (HCT) recipients. We describe the case of a young Italian man with Hodgkin lymphoma, who developed visceral leishmaniasis after multiple lines of chemotherapy and allogenic HCT. Literature review of visceral leishmaniasis in HCT recipients was also performed. Eleven patients (median age 50 years, 9 male) developed visceral leishmaniasis after allogenic (n = 9) and autologous (n = 2) HCT. Most of them presented with fever and pancytopenia. Bone marrow examination was the main diagnostic technique; liposomal amphotericin B was the treatment of choice. Four out of eight patients (for whom data are available) experienced visceral leishmaniasis relapse. Visceral leishmaniasis in HCT recipients is a rare event that should be suspected in patients with persistent fever, pancytopenia and possible exposure to Leishmania spp., remembering that - as well as South-East Asia, East Africa and South America - it is endemic in several European regions.
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Fabiani S, Fortunato S, Petrini M, Bruschi F. Allogeneic hematopoietic stem cell transplant recipients and parasitic diseases: A review of the literature of clinical cases and perspectives to screen and follow-up active and latent chronic infections. Transpl Infect Dis 2017; 19. [PMID: 28128496 DOI: 10.1111/tid.12669] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 10/20/2016] [Accepted: 10/29/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplant (HSCT) recipients are at substantial risk for a variety of infections depending upon numerous factors, such as degree of immunosuppression, host factors, and period after transplantation. Bacterial, fungal, viral, as well as parasitic infections can occur with high morbidity and mortality. OBJECTIVES The aim of this study was to evaluate the magnitude of the occurrence of parasitic infections in allogeneic HSCT recipients. Modalities of transmission, methods of diagnosis, treatment, donor and recipient pre-transplant screening and prevention measures of the most serious parasitic infections have also been discussed. MATERIALS AND METHODS We systematically reviewed literature records on post-transplant (allogeneic HSCT) parasitic infections, identified through PubMed database searching, using no language or time restrictions. Search was concluded on December 31, 2015. In the present review, we only discussed post-transplant parasitic infections in allogeneic HSCT. Only exclusion criteria were absence of sufficient information on the transmission of parasitic infection to the recipient. Autologous HSCT recipients have not been included because of the absence of a proper allogeneic transplantation even in presence of blood or blood product transfusions. The methods and findings of the present review have been reported based on the preferred reporting items for systematic reviews and meta-analysis checklist (PRISMA). RESULTS Regarding allogeneic HSCT recipients, from data published in the literature the real burden of parasitic infections cannot be really estimated. Nevertheless, a positive trend on publication number exists, probably because of more than one reason: (i) the increasing number of patients transplanted and then treated with immunosuppressive agents, (ii) the "population shift" resulting from immigration and travels to endemic areas, and (iii) the increasing of attention for diagnosis/notification/publication of cases. CONCLUSIONS Considering parasitic infections as emerging and potentially serious in their evolution, additional strategies for the prevention, careful screening and follow-up, with a high level of suspicion, identification, and preemptive therapy are necessary in transplant recipients. PERSPECTIVES The Authors' viewpoint in the perspective to screen and follow-up active and latent chronic parasitosis in stem cells donors and recipients: a proposal for a flow chart.
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Affiliation(s)
- Silvia Fabiani
- School of Infectious Diseases, Università di Pisa, Pisa, Italy
| | | | - Mario Petrini
- Department of Experimental and Clinical Medicine, Università di Pisa, Pisa, Italy.,Unit of Hematology, AOU Pisana, Pisa, Italy
| | - Fabrizio Bruschi
- School of Infectious Diseases, Università di Pisa, Pisa, Italy.,Department of Translational Research, N.T.M.S., Università di Pisa, Pisa, Italy
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Gajurel K, Dhakal R, Deresinski S. Leishmaniasis in solid organ and hematopoietic stem cell transplant recipients. Clin Transplant 2016; 31. [PMID: 27801541 DOI: 10.1111/ctr.12867] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2016] [Indexed: 01/05/2023]
Abstract
Leishmaniasis occurs in <1% of solid organ and hematopoietic stem cell transplant recipients in endemic countries in which transplants are performed. Visceral leishmaniasis (VL) makes up the bulk of reported cases. The onset generally occurs months after transplantation and the mode of acquisition is often impossible to determine, but de novo vector-borne infection and reactivation of inapparent infection are thought to be the principal means. The potential role of clinically inapparent donor infection is uncertain and screening is not currently recommended, nor is it recommended for recipients from endemic areas, some of whom may have detectable circulating protozoan nucleic acid. While transplant recipients with VL often present with the non-specific findings of fever and cytopenia, the additional presence of hepatosplenomegaly in patients from endemic areas should lead to a directed diagnostic evaluation with bone marrow examination and PCR testing of marrow and peripheral blood having a high yield. Management may often be complicated by the presence of concomitant infections. A lipid formulation of amphotericin B is the preferred treatment, especially for VL, but the relapse rate in transplant recipients is approximately 25%. PCR monitoring of blood for either secondary prophylaxis or preemptive therapy requires further study.
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Affiliation(s)
- Kiran Gajurel
- Division of Infectious Diseases, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Reshika Dhakal
- University of Iowa, Carver College of Medicine, Iowa City, IA, USA
| | - Stan Deresinski
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Parasitic Infections in Hematopoietic Stem Cell Transplantation. Mediterr J Hematol Infect Dis 2016; 8:e2016035. [PMID: 27413527 PMCID: PMC4928538 DOI: 10.4084/mjhid.2016.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 06/12/2016] [Indexed: 12/14/2022] Open
Abstract
Parasitic infections are rarely documented in hematopoietic stem cell transplant recipients. However they may be responsible for fatal complications that are only diagnosed at autopsy. Increased awareness of the possibility of parasitic diseases both in autologous and allogeneic stem cell transplant patients is relevant not only for implementing preventive measures but also for performing an early diagnosis and starting appropriate therapy for these unrecognized but fatal infectious complications in hematopoietic transplant recipients. In this review, we will focus on parasitic diseases occurring in this population especially those with major clinical relevance including toxoplasmosis, American trypanosomiasis, leishmaniasis, malaria, and strongyloidiasis, among others, highlighting the diagnosis and management in hematopoietic transplant recipients.
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Abstract
Visceral leishmaniasis (VL or kala-azar) is most endemic in Asia and Africa and commonly affects young children. It is usually caused by Leishmania donovani or Leishmania infantum that are transmitted by Phlebotomine sand flies. Transmission may be anthroponotic or zoonotic or both, depending on the endemic area. Clinical features include fever, hepatosplenomegaly, weight loss and pancytopenia. Younger age, malnutrition and immunosuppression (HIV infection, use of immunosuppressive drugs) are risk factors. Many infections remain asymptomatic. Diagnosis is made by demonstration of the Leishmania parasite in aspirates of lymph node, bone marrow or spleen. Serological tests such as rK39 strip test are widely used but the sensitivity varies. qPCR is useful to detect low numbers of parasites and to monitor treatment. Treatment is with AmBisome monotherapy in most areas but with drug combinations elsewhere. HIV co-infected patients are most difficult to treat and often relapse. Control efforts focus on case finding, availability of diagnostic tools, reservoir control and protection from sand flies (insecticides, bed nets). There is no human vaccine.
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Pierrotti LC, Kotton CN. Transplantation in the tropics: lessons on prevention and management of tropical infectious diseases. Curr Infect Dis Rep 2015; 17:492. [PMID: 26031964 DOI: 10.1007/s11908-015-0492-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Tropical infectious diseases (IDs) remain a rare complication in transplant recipients even in tropical settings, but this topic has become increasingly important during the last decade due to multiple factors. Interestingly, non-tropical countries report most of the experiences with tropical diseases. The reported experience from non-endemic regions, however, does not always reflect the experience of endemic areas. Most of the guidelines and recommendations in the literature may not be applicable in tropical settings due to logistical difficulties, cost, and lack of proven benefit. In addition, certain post-transplant prevention measures, as prophylaxis and reducing exposure risk, are not feasible. Nonetheless, risk assessment and post-transplant management of tropical IDs in tropical areas should not be neglected, and clinicians need to have a higher clinical awareness for tropical ID occurring in this population. Herein, we review the more significant tropical ID in transplant patients, focusing on relevant experience reported by tropical settings.
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Affiliation(s)
- Ligia C Pierrotti
- Infectious Diseases Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, 4° andar, São Paulo, 05403-900, SP, Brazil,
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