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Elhaj Mahmoud D, Hérivaux A, Morio F, Briard B, Vigneau C, Desoubeaux G, Bouchara JP, Gangneux JP, Nevez G, Le Gal S, Papon N. The epidemiology of invasive fungal infections in transplant recipients. Biomed J 2024; 47:100719. [PMID: 38580051 PMCID: PMC11220536 DOI: 10.1016/j.bj.2024.100719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/07/2024] Open
Abstract
Transplant patients, including solid-organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) recipients, are exposed to various types of complications, particularly rejection. To prevent these outcomes, transplant recipients commonly receive long-term immunosuppressive regimens that in turn make them more susceptible to a wide array of infectious diseases, notably those caused by opportunistic pathogens. Among these, invasive fungal infections (IFIs) remain a major cause of mortality and morbidity in both SOT and HSCT recipients. Despite the continuing improvement in early diagnostics and treatments of IFIs, the management of these infections in transplant patients is still complicated. Here, we provide an overview concerning the most recent trends in the epidemiology of IFIs in SOT and HSCT recipients by describing the prominent yeast and mold species involved, the timing of post-transplant IFIs and the risk factors associated with their occurrence in these particularly weak populations. We also give special emphasis into basic research advances in the field that recently suggested a role of the global and long-term prophylactic regimen in orchestrating various biological disturbances in the organism and conditioning the emergence of the most adapted fungal strains to the particular physiological profiles of transplant patients.
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Affiliation(s)
- Dorra Elhaj Mahmoud
- University of Angers, University of Brest, Infections Respiratoires Fongiques, SFR Interactions Cellulaires et Applications Thérapeutiques, Angers, France
| | - Anaïs Hérivaux
- University of Angers, University of Brest, Infections Respiratoires Fongiques, SFR Interactions Cellulaires et Applications Thérapeutiques, Angers, France
| | - Florent Morio
- Nantes Université, CHU Nantes, Cibles et Médicaments des Infections et de L'Immunité, UR1155, Nantes, France
| | - Benoit Briard
- INSERM, Centre d'Etude des Pathologies Respiratoires (CEPR), UMR 1100, Université de Tours, Faculté de Médecine de Tours, Tours, France; CHRU Tours, Parasitologie-Mycologie Médicale-Médecine Tropicale, Tours, France
| | - Cécile Vigneau
- University of Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail), UMR_S, 1085, Rennes, France; Division of Nephrology, Rennes University Hospital, Rennes, France
| | - Guillaume Desoubeaux
- INSERM, Centre d'Etude des Pathologies Respiratoires (CEPR), UMR 1100, Université de Tours, Faculté de Médecine de Tours, Tours, France; CHRU Tours, Parasitologie-Mycologie Médicale-Médecine Tropicale, Tours, France
| | - Jean-Philippe Bouchara
- University of Angers, University of Brest, Infections Respiratoires Fongiques, SFR Interactions Cellulaires et Applications Thérapeutiques, Angers, France
| | - Jean-Pierre Gangneux
- University of Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail), UMR_S, 1085, Rennes, France; Laboratory of Parasitology and Medical Mycology, European Confederation of Medical Mycology (ECMM) Excellence Center, Centre National de Référence Aspergilloses Chroniques, Rennes University Hospital, Rennes, France
| | - Gilles Nevez
- Laboratory of Parasitology and Mycology, Brest University Hospital, Brest, France; University of Brest, University of Angers, Infections Respiratoires Fongiques, SFR Interactions Cellulaires et Applications Thérapeutiques, Brest, France
| | - Solène Le Gal
- Laboratory of Parasitology and Mycology, Brest University Hospital, Brest, France; University of Brest, University of Angers, Infections Respiratoires Fongiques, SFR Interactions Cellulaires et Applications Thérapeutiques, Brest, France
| | - Nicolas Papon
- University of Angers, University of Brest, Infections Respiratoires Fongiques, SFR Interactions Cellulaires et Applications Thérapeutiques, Angers, France.
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2
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Barros K, Tepper JW, Ramchandani J, Kelley MK, Kussin ML, Israel EN, Tompkins MG, Alali M. Unusual presentation of disseminated cryptococcal infection complicated by myocarditis in a heart transplant recipient. Pediatr Transplant 2024; 28:e14585. [PMID: 37489596 DOI: 10.1111/petr.14585] [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: 11/27/2022] [Revised: 06/21/2023] [Accepted: 07/10/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Cryptococcus neoformans is the third most common cause of invasive fungal infection in solid organ transplant (SOT) recipients. While cryptococcal infection can involve any organ, cases of myocarditis are exceedingly rare. METHODS A retrospective chart review was completed for this case report. RESULTS We present the case of a 21-year-old heart transplant recipient who developed disseminated cryptococcal infection with biopsy-proven cryptococcal myocarditis. CONCLUSIONS Cryptococcal disease in SOT recipients poses diagnostic and therapeutic challenges. There are no current guidelines for the duration of cryptococcal myocarditis treatment. Repeat myocardial biopsy may play a role in guiding length of therapy.
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Affiliation(s)
- Kathryn Barros
- Ryan White Center for Pediatric Infectious Diseases & Global Health, Indiana University, Indianapolis, Indiana, USA
| | - John William Tepper
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Juhi Ramchandani
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Meagan Kristine Kelley
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Michelle L Kussin
- Pediatric Infectious Diseases, Department of Pharmacy, Riley Hospital for Children at Indiana University Health and Ryan White Center for Pediatric Infectious Diseases & Global Health, Indiana University, Indianapolis, Indiana, USA
| | - Emily N Israel
- Purdue College of Pharmacy, West Lafayette, Indiana, USA
- Department of Pharmacy, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
| | - Madeline G Tompkins
- Pediatric Cardiology, Department of Pharmacy, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
| | - Muayad Alali
- Ryan White Center for Pediatric Infectious Diseases & Global Health, Indiana University, Indianapolis, Indiana, USA
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3
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Cumagun PM, Moore MK, McCarty TP, McGwin G, Pappas PG. Cryptococcal Meningoencephalitis in Phenotypically Normal Patients. Pathogens 2023; 12:1303. [PMID: 38003768 PMCID: PMC10674724 DOI: 10.3390/pathogens12111303] [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: 07/03/2023] [Revised: 09/20/2023] [Accepted: 09/28/2023] [Indexed: 11/26/2023] Open
Abstract
Cryptococcosis is an invasive fungal infection found worldwide that causes significant morbidity and mortality among a broad range of hosts. There are approximately 223,000 new cases of cryptococcosis annually throughout the world, and at least 180,000 deaths are attributed to this infection each year. Most of these are due to complications of cryptococcal meningoencephalitis among HIV-infected patients in resource-limited environments. The majority of individuals diagnosed with cryptococcosis have underlying conditions associated with immune dysfunction such as HIV, solid organ transplant, hematologic malignancy, organ failure syndromes, and/or the use of immunosuppressive agents such as glucocorticosteroids and biologic agents. In most clinical series, there is a small proportion of patients with cryptococcosis who are phenotypically normal; that is, they have no clinically obvious predisposition to disease. Cryptococcal meningoencephalitis (CME) presentation and management differ substantially between these normal individuals and their immunocompromised counterparts. In this review, we will focus on CME in the phenotypically normal host and underscore differences in the clinical presentation, management, outcome, and potential risk factors for these patients compared to immunocompromised persons who develop this potential devastating invasive fungal infection.
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Affiliation(s)
- Pia M. Cumagun
- Department of Medicine, Division of Infectious Diseases, The University of Alabama at Birmingham, Birmingham, AL 35294, USA; (P.M.C.)
| | | | - Todd P. McCarty
- Department of Medicine, Division of Infectious Diseases, The University of Alabama at Birmingham, Birmingham, AL 35294, USA; (P.M.C.)
| | - Gerald McGwin
- Department of Epidemiology, School of Public Health, University of Alabama, Birmingham, AL 35294, USA
| | - Peter G. Pappas
- Department of Medicine, Division of Infectious Diseases, The University of Alabama at Birmingham, Birmingham, AL 35294, USA; (P.M.C.)
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4
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Chen S, Yu G, Chen M, You Y, Gu L, Wang Q, Wang H, Lai G, Yu Z, Wen W. Comparison of different therapeutic approaches for pulmonary cryptococcosis in kidney transplant recipients: a 15-year retrospective analysis. Front Med (Lausanne) 2023; 10:1107330. [PMID: 37484845 PMCID: PMC10361058 DOI: 10.3389/fmed.2023.1107330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 06/15/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction Organ transplant recipients are at increased risk of developing pulmonary cryptococcosis (PC) due to weakened cell-mediated immunity caused by immunosuppressors. However, the nonspecific symptoms associated with PC can often lead to misdiagnosis and inappropriate treatment. Methods We conducted a retrospective analysis of data from 23 kidney transplant recipients with PC between April 2006 to January 2021. Results The median time from transplantation to the diagnosis of pathology-proven PC 4.09 years. Seventeen patients presented respiratory symptoms, including sputum-producing cough and dyspnea. Additionally, three patients also developed central nervous system (CNS) infections. Chest CT scans frequently revealed nodule-shaped lesions, which can mimic lung carcinoma. Serological tests did not demonstrate any specific changes. Nine patients received surgical resection as treatment. Fourteen patients were treated with antifungal medication only. No recurrence was observed in all 23 patients. Conclusion Our study suggests that fever and sputum-producing cough are common symptoms of PC, and cryptococcal meningitis should not be excluded if corresponding symptoms occur. Fluconazole is a common and effective antifungal agent. Surgical resection should be considered for patients who do not respond well to antifungal therapy. Clinicians should be aware of these findings when evaluating transplant recipients with respiratory symptoms.
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Affiliation(s)
- Shuyang Chen
- Department of Respiratory and Critical Care Medicine, Fuzhou General Hospital of Fujian Medical University, Dongfang Hospital of Xiamen University, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guoqing Yu
- Department of Nephrology, Fuzhou General Hospital of Fujian Medical University, Dongfang Hospital of Xiamen University, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
| | - Meiyan Chen
- Department of Respiratory and Critical Care Medicine, Fuzhou General Hospital of Fujian Medical University, Dongfang Hospital of Xiamen University, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
| | - Yanjing You
- Department of Respiratory and Critical Care Medicine, Fuzhou General Hospital of Fujian Medical University, Dongfang Hospital of Xiamen University, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
| | - Lei Gu
- The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qing Wang
- The Third Affiliated People’s Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Huijuan Wang
- Department of Respiratory and Critical Care Medicine, Fuzhou General Hospital of Fujian Medical University, Dongfang Hospital of Xiamen University, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
| | - Guoxiang Lai
- Department of Respiratory and Critical Care Medicine, Fuzhou General Hospital of Fujian Medical University, Dongfang Hospital of Xiamen University, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
| | - Zongyang Yu
- Department of Respiratory and Critical Care Medicine, Fuzhou General Hospital of Fujian Medical University, Dongfang Hospital of Xiamen University, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
| | - Wen Wen
- Department of Respiratory and Critical Care Medicine, Fuzhou General Hospital of Fujian Medical University, Dongfang Hospital of Xiamen University, The 900th Hospital of the Joint Logistic Support Force, Fuzhou, China
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5
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La Hoz RM. Minimizing the Risk of Donor-Derived Events and Maximizing Organ Utilization Through Education and Policy Development. Infect Dis Clin North Am 2023:S0891-5520(23)00044-2. [PMID: 37302913 DOI: 10.1016/j.idc.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Herein, we review the current knowledge of donor-derived disease and current US Organ Procurement and Transplantation Network policies to minimize the risk. During the process, we also consider actions to further mitigate the risk of donor-derived disease. The overarching goal is to provide an infectious disease perspective on the complex decision of organ acceptance for transplant programs and candidates.
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Affiliation(s)
- Ricardo M La Hoz
- Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9913, USA.
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6
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Sha M, Shen C, Tong Y, Xia Q. Cluster of Donor-Derived Cryptococcosis after Liver and Kidney Transplantation. Emerg Infect Dis 2022; 28:2112-2114. [PMID: 36148992 PMCID: PMC9514340 DOI: 10.3201/eid2810.220522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cryptococcosis infection after transplantation is easily overlooked or misdiagnosed. We report a cluster of donor-derived cryptococcosis infection in liver and kidney transplant recipients from the same donor in China. Infections occurred within 1 month after transplantation, and were confirmed by using biopsies and blood tests.
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7
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Natarajan P, Lockhart SR, Basavaraju SV, Anjan S, Lindsley MD, McGrath MM, Oh DH, Jackson BR. Donor-derived Cryptococcus gattii sensu stricto infection in two kidney transplant recipients, southeastern United States. Am J Transplant 2021; 21:3780-3784. [PMID: 34173328 DOI: 10.1111/ajt.16729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 01/25/2023]
Abstract
Cryptococcus gattii infection is a rare cause of severe pulmonary disease and meningoencephalitis that has only recently been detected in the southeastern United States. We describe an organ transplant-associated outbreak of C. gattii infection involving an HIV-negative immunosuppressed donor in this region who died following new-onset headache and seizure of unknown cause. Retrospective cryptococcal antigen (CrAg) testing of donor serum was positive. Two of the three transplant recipients developed severe C. gattii infection 11 and 12 weeks following transplantation. One recipient died from severe pulmonary infection, identified on autopsy, and the other ill recipient survived following treatment for cryptococcal meningitis. This outbreak underscores the importance of considering cryptococcosis in patients with clinical findings suggestive of subacute meningitis or other central nervous system (CNS) pathology, and the potential benefit of routine pre-transplant donor CrAg screening using lateral flow assay to guide recipient antifungal prophylaxis. The case also adds to emerging evidence that C. gattii is a potential threat in the southeastern United States.
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Affiliation(s)
| | | | - Sridhar V Basavaraju
- CDC, Atlanta, Georgia, USA.,U.S. Public Health Service, Rockville, Maryland, USA
| | - Shweta Anjan
- Miami Transplant Institute, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | | | - Martina M McGrath
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David H Oh
- Kaiser Permanente Oakland Medical Center, Oakland, California, USA
| | - Brendan R Jackson
- CDC, Atlanta, Georgia, USA.,U.S. Public Health Service, Rockville, Maryland, USA
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8
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Cryptococcus neoformans Infective Endocarditis After Lung Transplantation. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2021; 29:e457-e461. [DOI: 10.1097/ipc.0000000000001030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Santos DWCL, Hagen F, Meis JF, Cristelli MP, Viana LA, Bernardi FDC, Tedesco-Silva H, Medina-Pestana JO, Colombo AL. Donor-Derived Transmission of Cryptococcus gattii sensu lato in Kidney Transplant Recipients. Emerg Infect Dis 2021; 26:1329-1331. [PMID: 32441623 PMCID: PMC7258454 DOI: 10.3201/eid2606.191765] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
We describe cases of donor-derived transmission of Cryptococcus deuterogattii in 2 kidney transplant recipients in Brazil and published information on other cases. Prompt reduction of immunosuppression and initiation of antifungal therapy was required to successfully control the fungal infections and preserve engraftment.
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10
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Abstract
Cryptococcosis is an invasive fungal infection of global significance caused by yeasts of the genus Cryptococcus. The prevalence of HIV in certain areas of the world and the expanding population of immunocompromised patients contribute to the ongoing global disease burden. Point-of-care serologic testing has allowed for more rapid diagnosis and implementation of screening programs in resource-limited settings. Management involves therapy aimed at reduction in fungal burden, maintenance of intracranial pressure, and optimization of host immunity. Despite diagnostic and therapeutic advances, cryptococcosis continues to be a disease with unacceptably high incidence and mortality, particularly in resource-limited settings.
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Affiliation(s)
- Alexis C Gushiken
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201, USA
| | - Kapil K Saharia
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201, USA
| | - John W Baddley
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201, USA.
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11
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Penumarthi LR, La Hoz RM, Wolfe CR, Jackson BR, Mehta AK, Malinis M, Danziger-Isakov L, Strasfeld L, Florescu DF, Vece G, Basavaraju SV, Michaels MG. Cryptococcus transmission through solid organ transplantation in the United States: A report from the Ad Hoc Disease Transmission Advisory Committee. Am J Transplant 2021; 21:1911-1923. [PMID: 33290629 PMCID: PMC8096655 DOI: 10.1111/ajt.16433] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/30/2020] [Accepted: 11/30/2020] [Indexed: 01/25/2023]
Abstract
Cryptococcus species can cause serious life-threatening infection in solid organ transplant recipients by reactivation of prior infection, posttransplant de novo infection, or donor transmission from the transplanted organ. Although previously reported in the literature, the extent of donor-derived cryptococcosis in the United States has not been documented. We analyzed potential donor-derived Cryptococcus transmission events reported to the Organ Procurement and Transplantation Network (OPTN) for investigation by the Ad Hoc Disease Transmission Advisory Committee (DTAC). All reports between 2009 and 2019 in which transmission to recipients was designated proven or probable, or determined to be averted due to implementation of prophylaxis (intervention without disease transmission-"IWDT") were included. During 2009-2019, 58 reports of potential donor-derived cryptococcosis were submitted to DTAC. Among these reports, 12 donors were determined to have resulted in proven or probable transmission to 23/34 (67.6%) recipients. Most of these donors (10/12 [83%]) exhibited central nervous system-related symptoms prior to death and 5/23 (22%) infected recipients died. For 11 different donors, prophylaxis, most often with fluconazole, was administered to 23/35 (65.7%) recipients. Clinicians should maintain awareness of donor-derived cryptococcosis and consider prompt prophylaxis or treatment followed by reporting to OPTN for further investigation.
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Affiliation(s)
- Lasya R. Penumarthi
- Office of Blood, Organ, and Other Tissue Safety, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ricardo M. La Hoz
- Division of Infectious Disease and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Cameron R. Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC
| | - Brendan R. Jackson
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Aneesh K. Mehta
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
| | - Maricar Malinis
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT
| | - Lara Danziger-Isakov
- Department of Pediatrics, Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center & University of Cincinnati, Cincinnati, OH
| | - Lynne Strasfeld
- Department of Infection Prevention and Control, Division of Infectious Diseases, Oregon Health and Science University, Portland, OR
| | - Diana F. Florescu
- Infectious Diseases Division, Transplant Infectious Diseases Program, University of Nebraska Medical Center, Omaha, NE
| | | | - Sridhar V. Basavaraju
- Office of Blood, Organ, and Other Tissue Safety, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Marian G. Michaels
- Department of Pediatrics, Division of Pediatric Infectious Diseases University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh
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12
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van den Bogaart L, Cipriano A, Koutsokera A, Manuel O. Understanding rare infections post-lung transplantation. Expert Rev Respir Med 2020; 15:325-338. [PMID: 33106068 DOI: 10.1080/17476348.2021.1843428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Introduction: Lung transplant recipients are at the highest risk of infectious complications among all solid-organ transplant (SOT) recipients. In the current era, many standardized protocols in terms of diagnostic algorithms, prophylaxis, and therapeutic strategies have improved the management of the most common infectious complications. Conversely, diagnosis of rare infections can be particularly challenging and this can delay appropriate treatment.Areas covered: This article will review the epidemiology, clinical presentation, diagnostic and therapeutic management of certain rarely reported viral, fungal, bacterial and parasitic infections in lung transplant recipients.Expert opinion: Once the most frequent infections are excluded, clinical suspicion combined with molecular diagnostic methods such as targeted and broad-spectrum PCRs can allow diagnosis of a rare infection. A multidisciplinary team, including transplant pulmonologists, transplant infectious diseases specialists, microbiologists and pathologists is essential for prompt diagnosis and optimal therapeutic management.
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Affiliation(s)
- Lorena van den Bogaart
- Infectious Diseases Service, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Transplantation Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Ana Cipriano
- Infectious Disease Department, Centro Hospitalar Do Porto, Porto, Portugal
| | - Angela Koutsokera
- Division of Pulmonology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Oriol Manuel
- Infectious Diseases Service, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Transplantation Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
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13
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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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14
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Abstract
Transplants have become common with excellent patient and graft outcomes owing to advances in surgical technique, immunosuppression, and antimicrobial prophylaxis. In 2017, 34,770 solid organ transplants were performed in the United States. For solid organ transplant recipients, infection remains a common complication owing to the regimens required to prevent rejection. Opportunistic infections, which are infections that are generally of lower virulence within a healthy host but cause more severe and frequent disease in immunosuppressed individuals, typically occur in the period 1 month to 1 year after transplantation. This article focuses on opportunistic infections in the solid organ transplant recipient.
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Affiliation(s)
- Rebecca Kumar
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael G Ison
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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15
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Marinelli T, Anagnostou N, Daniel S, Wigg AJ, Teh J. Very early-onset of Cryptococcus neoformans disease following liver transplantation: Report of two cases and a review of the literature. Transpl Infect Dis 2019; 22:e13227. [PMID: 31785187 DOI: 10.1111/tid.13227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/10/2019] [Accepted: 11/24/2019] [Indexed: 01/14/2023]
Abstract
Cryptococcosis is the third most common invasive fungal infection following solid organ transplantation, and mortality is high. Most cases occur late and are due to reactivation of latent infection; however, very early reactivation and donor-derived transmission can occur. Routine screening pre-transplant and antifungal prophylaxis for cryptococcosis post-transplant in solid organ transplantation are not standard practice. We present two cases of very early-onset Cryptococcus neoformans disease following liver transplantation to highlight the need to consider individualized pre-transplant screening and be aware that reactivation of Cryptococcosis neoformans can occur in the immediate post-transplant period.
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Affiliation(s)
- Tina Marinelli
- Department of Infectious Diseases, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Nicholas Anagnostou
- Department of Infectious Diseases, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Santhosh Daniel
- Department of Infectious Diseases, Flinders Medical Centre, Bedford Park, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Alan J Wigg
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia.,Hepatology and Transplantation Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Joanne Teh
- Department of Infectious Diseases, Flinders Medical Centre, Bedford Park, South Australia, Australia
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16
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Cryptococcosis in Patients following Kidney Transplantation: A 9-Year Retrospective Clinical Analysis at a Chinese Tertiary Hospital. BIOMED RESEARCH INTERNATIONAL 2019; 2019:7165160. [PMID: 31828122 PMCID: PMC6885150 DOI: 10.1155/2019/7165160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 09/14/2019] [Accepted: 10/24/2019] [Indexed: 12/27/2022]
Abstract
Background Cryptococcosis following kidney transplantation (KT) is rare but is associated with considerably increased risk of mortality. At present, data on the association between cryptococcosis and KT in mainland China remain relatively limited. Objectives This study aims to review our experience related to the management of cryptococcosis following KT at a Chinese tertiary hospital. Methods All patients with cryptococcosis following KT admitted to our hospital from January 2010 to December 2018 were reviewed. Results A total of 37 patients with cryptococcosis were enrolled (males: 62.2%). The mean age of the patients was 49.5 ± 9.38 (20-64) years. The average time to infection following KT was 7.0 ± 5.50 years (5 months to 21 years), and 30 patients (81.1%) had cryptococcosis onset >2 years following transplantation. The most common site of infection was the central nervous system, followed by the pulmonary system and skin. Most patients received fluconazole or voriconazole with or without flucytosine as their initial treatment regimen at our hospital. The 2-week mortality rate was 8.1% (3/37), and five patients (13.5%) died within 6 months of being diagnosed with cryptococcosis. Remarkably, all patients who received high-dose fluconazole (800 mg daily) or voriconazole ± flucytosine survived. Conclusions Cryptococcosis in kidney transplant recipients is typically a late-occurring infection, with most patients having cryptococcosis onset >2 years following KT at our hospital. The central nervous system, pulmonary system, and skin are the main sites of infection. Voriconazole or high-dose fluconazole can be used as an alternative therapy for post-KT cryptococcosis.
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Dulek DE, Mueller NJ. Pneumonia in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13545. [PMID: 30900275 PMCID: PMC7162188 DOI: 10.1111/ctr.13545] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 03/18/2019] [Indexed: 12/19/2022]
Abstract
These guidelines from the AST Infectious Diseases Community of Practice review the diagnosis and management of pneumonia in the post-transplant period. Clinical presentations and differential diagnosis for pneumonia in the solid organ transplant recipient are reviewed. A two-tier approach is proposed based on the net state of immunosuppression and the severity of presentation. With a lower risk of opportunistic, hospital-acquired, or exposure-specific pathogens and a non-severe presentation, empirical therapy may be initiated under close clinical observation. In all other patients, or those not responding to the initial therapy, a more aggressive diagnostic approach including sampling of tissue for microbiological and pathological testing is warranted. Given the broad range of potential pathogens, a microbiological diagnosis is often key for optimal care. Given the limited literature comparatively evaluating diagnostic approaches to pneumonia in the solid organ transplant recipient, much of the proposed diagnostic algorithm reflects clinical experience rather than evidence-based data. It should serve as a template which may be modified according to local needs. The same holds true for the suggested empiric therapies, which need to be adapted to the local resistance patterns. Further study is needed to comparatively evaluate diagnostic and empiric treatment strategies in SOT recipients.
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Affiliation(s)
- Daniel E Dulek
- Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nicolas J Mueller
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zürich, Switzerland
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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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Camargo JF, Simkins J, Anjan S, Guerra G, Vianna R, Salama S, Albright C, Shipman E, Montoya J, Morris MI, Abbo LM. Implementation of a Strongyloides screening strategy in solid organ transplant donors and recipients. Clin Transplant 2019; 33:e13497. [PMID: 30773692 DOI: 10.1111/ctr.13497] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 01/09/2019] [Accepted: 02/09/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Strongyloides stercoralis infects 100 million people worldwide. Mortality rates in hyperinfection syndrome exceed 50%. Donor-derived Strongyloides infection has occurred after heart, kidney, kidney-pancreas and liver transplantation; yet, only 10% of the US organ procurement organizations currently screen donors for strongyloidiasis. METHODS We report a fatal case of donor-derived disseminated Strongyloides infection in a liver transplant recipient. Following this case, we implemented universal screening and treatment of donors and recipients. We reviewed our local epidemiology and outcomes after protocol implementation. RESULTS From a total of 355 deceased donors accepted at our center between January 2016, and March 2018, 14 (3.9%) had positive Strongyloides serology. Except for the index case, all other recipients of Strongyloides antibody-positive donors within that period (including 10 kidneys, 3 livers, one combined liver/kidney, and one kidney/pancreas from eight seropositive donors) received post-transplant prophylaxis with ivermectin, and to date are alive and doing well without signs of infection. Between October 2015, and September 2016, a total of 441 deceased donor solid organ transplants were performed at our center. 220 of these recipients had pretransplant Strongyloides serology available, and 23 of them were seropositive (10.5%). Within the first two years after the implementation of universal screening and treatment of donors and recipients, we had no cases of Strongyloides reactivation in our center. CONCLUSIONS Implementation of a Strongyloides screening and treatment protocol in our center was an effective strategy to prevent both recipient- and donor-derived strongyloidiasis. Transplant centers should consider implementation of Strongyloides preventive strategies.
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Affiliation(s)
- Jose F Camargo
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Jacques Simkins
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Shweta Anjan
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | | | | | - Sam Salama
- Life Alliance Organ Recovery Agency, Miami, Florida
| | | | | | | | - Michele I Morris
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Lilian M Abbo
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
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Bini Viotti J, Loebe M, Brozzi N, Pinto A, Simkins J, Cloke CM, Camargo JF, Salama S, Abbo LM. Solving the mystery: Hyalinized cyst wall containing organism-like structures in a lung transplant donor. Transpl Infect Dis 2018; 20:e12940. [PMID: 29873170 DOI: 10.1111/tid.12940] [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: 04/12/2018] [Revised: 05/11/2018] [Accepted: 05/28/2018] [Indexed: 11/30/2022]
Abstract
A 59-year-old man with non-ischemic cardiomyopathy underwent orthotopic heart transplantation. The donor, a 31-year-old male declared brain dead after a gunshot wound to the head, was considered high risk due to history of incarceration, illicit drug use, and sex with a HIV-positive partner. At organ procurement, the heart, kidneys, pancreas, and liver looked grossly normal. A small right lower lobe nodule was noticed, and lung biopsy was performed. Bronchoscopy showed purulent secretions in the right lower lobe. Images from pathology are presented. Lung biopsy confirmed the presence of hyalinized cyst wall containing organism-like structures. A combination of culture, microscopic morphology, and gene sequencing was used to identify the causative organism. The patient and all other organ recipients received appropriate antifungal prophylaxis and remain asymptomatic 6 months post-transplant.
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Affiliation(s)
- Julia Bini Viotti
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Matthias Loebe
- Department of Cardiothoracic Surgery, University of Miller School of Medicine, Miami, FL, USA
| | - Nicolas Brozzi
- Department of Cardiothoracic Surgery, University of Miller School of Medicine, Miami, FL, USA
| | - Andre Pinto
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jacques Simkins
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Christina M Cloke
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jose F Camargo
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Sam Salama
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Lilian M Abbo
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
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