Allergic bronchopulmonary aspergillosis in lung allograft recipients

Allergic bronchopulmonary aspergillosis in a lung transplant recipient treated with mepolizumab

Allergic bronchopulmonary aspergillosis (ABPA) is a complex hypersensitivity reaction to Aspergillus spp. ABPA diagnosis may be challenging due to its non-specific presentation. Standard ABPA treatment consists of systemic corticosteroids and antifungal agents. Mepolizumab, a monoclonal antibody against interleukin-5 seems to be a promising treatment for ABPA. Data about ABPA following lung transplantation (LuTx) are scarce. LuTx recipients are at higher risk for adverse effects of ABPA treatment compared to the general population. Here we present a case of a LuTx recipient who was successfully treated with mepolizumab for ABPA following LuTx. Prolonged administration of high dose prednisone was thus avoided. To our knowledge, this is the first case describing mepolizumab administration following LuTx. Mepolizumab seems particularly attractive as a corticosteroid-sparing agent or as an alternative option to antifungal treatments, because of its excellent safety profile and low risk of drug interactions.

Lung transplantation for cystic fibrosis: results, indications, complications, and controversies

Survival in patients with cystic fibrosis (CF) has improved dramatically over the past 30 to 40 years, with mean survival now approximately 40 years. Nonetheless, progressive respiratory insufficiency remains the major cause of mortality in CF patients, and lung transplantation (LT) is eventually required. Timing of listing for LT is critical, because up to 25 to 41% of CF patients have died while awaiting LT. Globally, approximately 16.4% of lung transplants are performed in adults with CF. Survival rates for LT recipients with CF are superior to other indications, yet LT is associated with substantial morbidity and mortality (∼50% at 5-year survival rates). Myriad complications of LT include allograft failure (acute or chronic), opportunistic infections, and complications of chronic immunosuppressive medications (including malignancy). Determining which patients are candidates for LT is difficult, and survival benefit remains uncertain. In this review, we discuss when LT should be considered, criteria for identifying candidates, contraindications to LT, results post-LT, and specific complications that may be associated with LT. Infectious complications that may complicate CF (particularly Burkholderia cepacia spp., opportunistic fungi, and nontuberculous mycobacteria) are discussed.

Pulmonary infections after lung transplantation

A tüdőtranszplantáció napjainkban már rutinszerűen végzett beavatkozássá vált a végstádiumú parenchymás és vascularis tüdőbetegségekben. Az elmúlt két évtized során több mint 20 ezer tüdőtranszplantációt végeztek a világon. Az immunszuppresszív szerek fejlődésének eredményeként az életet veszélyeztető akut rejekciók száma jelentősen csökkent, az első éven belüli halálozás csupán 2%-át okozza. A legnagyobb arányban az infekciók felelősek a korai és a késői morbiditásért és mortalitásért. A posztoperatív első 30 napon belüli halálozás 21,2%-a, az első éven belüli halálozás 40%-a infekciós eredetű. Az első hónapban a betegek 35–70%-ánál bakteriális pneumónia alakul ki, amelynek kb. felét Gram-negatív pálcák okozzák, dominálóan Pseudomonas-törzsek. A betegek a műtétet követően antibiotikus profilaxisban részesülnek, amit aztán a donortüdőből kimutatott törzs rezisztenciatesztje alapján módosíthatunk. A korai posztoperatív időszakban az invazív gomba- (Aspergillus-, Candida-) és CMV-infekciók a 100 napig tartó inhalatív amphotericin és szisztémás valganciklovir-profilaxis hatására kevesebb mint 10–10%-ban lépnek fel. Számuk a profilaxis befejezte után emelkedik. A későbbiekben kialakuló bronchiolitis obliterans szindróma (BOS) szintén hajlamosít a fertőzésekre. Ennek jelentőségét az adja, hogy 5 évvel a műtét után a betegek kb. 50%-ánál detektálható a BOS. Az infekciók sikeres leküzdésének alapja a rutinszerűen, illetve a tünetek fellépte után minél hamarabb elvégzett kontroll (laboratóriumi, radiológiai, légzésfunkciós, köpet- és bronchoszkópos vizsgálatok), majd a célzott terápia bevezetése. A munka célja a tüdőtranszplantáltaknál jelentkező leggyakoribb infekciók klinikai manifesztációjának, diagnosztikájának és kezelésének áttekintése.

Lung transplantation for cystic fibrosis: Current concepts and one center's experience

BACKGROUND

Although new approaches to the treatment of patients with cystic fibrosis (CF) are significantly prolonging their lives, most patients will eventually develop respiratory failure due to progressive bronchiectasis caused by chronic lung infection and inflammation and die from to respiratory failure. We examined our center's (University of Wisconsin Hospital and Clinics) experience with lung transplantation for patients with CF and reviewed the literature to examine current and evolving approaches to transplantation for this indication.

METHODS

We reviewed all published literature pertaining to lung transplantation for CF through 2006, and we reviewed all aspects of transplantation for patients with CF at our institution from 1994 to 2005.

RESULTS

Major complications following lung transplantation include acute rejection, bacterial infection, and bronchiolitis obliterans. Five-year survival at UWHC (Kaplan-Meier) is 67%, and survival was not adversely affected by transplanting patients receiving mechanical ventilation. The major cause of death for transplant recipients was bronchiolitis obliterans syndrome (BOS).

CONCLUSIONS

Lung transplantation for CF is associated with acceptable survival rates and can improve quality of life. Lung transplant should be offered to all patients with advanced CF lung disease if they meet currently accepted inclusion and exclusion criteria.

Allergic bronchopulmonary aspergillosis in a lung transplant patient successfully treated with nebulized amphotericin

A case of allergic bronchopulmonary Aspergillosis (ABPA) complicating lung transplantation for cystic fibrosis is described. Control of ABPA was only achieved with 20 mg of prednisone and 600 mg of itraconazole per day. However, a prompt clinical and physiologic response was observed when nebulized amphotericin was introduced, which allowed prednisone to be reduced to 7.5 mg per day and, in time, all anti-fungal therapy to be withdrawn.

Aspergillosis in lung transplantation: incidence, risk factors, and prophylactic strategies

Invasive aspergillosis remains a significant cause of morbidity and mortality in transplantation, especially lung and allogeneic bone marrow transplant recipients. The epidemiology, classic and newly recognized risk factors, and incidence of aspergillosis are reviewed. Risk factors include environmental exposures, airway colonization, profound immunosuppression, neutropenia, prior cytomegalovirus infection, and renal dysfunction. Clinical and radiographic presentations of invasive aspergillosis are discussed, including some unusual manifestations in lung transplant recipients. Early and accurate diagnosis of aspergillosis remains a challenge, and diagnostic strategies are reviewed, with an emphasis on the chest computerized tomography scan and on transbronchial or open lung biopsy. Recent advances include prophylactic and pre-emptive antifungal strategies, newer therapeutic agents, and improved risk stratification.

Spectrum of Aspergillus infection in lung transplant recipients: case series and review of the literature

STUDY OBJECTIVES

(1) To define the incidence and natural history of Aspergillus colonization and infection in lung transplant recipients, and (2) to assess the impact of prophylaxis, surveillance, and therapy on the incidence and outcome of the disease.

DESIGN

Retrospective review of 133 consecutive single or bilateral lung transplantations performed at a single institution, and review of the published literature.

RESULTS

Airway colonization, isolated tracheobronchitis, and invasive pneumonia due to Aspergillus species occurred in 29%, 5%, and 8% of our series, and in 26%, 4%, and 5% of the pooled published data (all series, including ours), respectively. Greater than 50% of all diagnoses were made in the first 6 months after transplantation in both our series and the published literature. Incidence of progression from airway colonization to invasive disease was 1 in 38 in our series and 3 of 97 (3%) in the pooled published data. In patients with isolated tracheobronchitis, all 6 patients in our series and 41 of 50 patients (82%) in all published series, including ours, responded to antifungal therapy and/or surgical debridement. Among patients with invasive pneumonia or disseminated disease, however, 5 of 10 patients in our series and 26 of 64 patients (41%) in the pooled series survived their infection.

CONCLUSIONS

The role of antifungal therapy in Aspergillus airway colonization in lung transplant recipients is unclear. Data support a strategy of scheduled screening bronchoscopy followed by aggressive treatment for isolated Aspergillus tracheobronchitis in lung transplant recipients.

Antifungal prophylaxis during the early postoperative period of lung transplantation. Valencia Lung Transplant Group

INTRODUCTION

Fungal infections occur frequently in lung transplant patients, with the highest risk being in the early postoperative period (the initial hospitalization after lung transplantation). Aspergillus is responsible for more than half of all fungal infections, and Aspergillus has even been considered a contraindication for lung transplantation because of its difficult therapy and frequently fatal outcome. The aim of this article is to evaluate the success of an antifungal prophylaxis protocol to prevent fungal infection in the immediate postoperative period in lung transplant recipients.

MATERIAL AND METHODS

From March 1994 to March 1997, we performed 52 lung transplants in 31 men and 21 women who received antifungal prophylaxis with fluconazole, 400 mg/d, and aerosolized amphotericin B, 0.6 mg/kg/d, during the postoperative period.

RESULTS

The mean (+/- SD) postoperative period duration was 49 +/- 27.5 days. No fungal infections were observed during this period, and all patients provided negative cultures. We also found no toxicity related to antifungal drugs. The dose of cyclosporine was easily adjusted in every recipient according to blood levels so that effective immunosuppression was not compromised.

DISCUSSION

In our study, the removal of the lungs and antifungal prophylaxis with fluconazole and aerosolized amphotericin B prevented fungal infection in the postoperative period in all 52 lung transplant recipients.

Pulmonary aspergillosis in cystic fibrosis lung transplant recipients

STUDY OBJECTIVE

To define the prevalence of colonization and infection of the lower respiratory tract (LRT) with Aspergillus in lung transplant recipients with and without cystic fibrosis (CF).

DESIGN

Retrospective review.

SETTING

Large university lung transplant center.

MATERIALS AND METHODS

The postoperative course of 31 CF and 53 non-CF double lung or double lobar transplant recipients receiving allografts from April 1991 to February 1996 was reviewed. All recipients were subjected to surveillance bronchoscopy and biopsy at predetermined intervals and when clinically indicated. BAL fluid (BALF) and biopsy material were examined by appropriate fungal culture and staining techniques. Infection was defined by the finding of tissue-invasive disease on biopsy specimens.

RESULTS

Seven of the 31 CF recipients (22%) had Aspergillus isolated from cultures of sputum prior to transplantation. Following transplantation, 15 CF recipients (48%) had Aspergillus isolated from either sputum or BALF, including 4 of the 7 recipients identified with the fungus prior to transplantation. By contrast, 21 of the 53 non-CF recipients (40%) had Aspergillus isolated from the LRT following transplantation, none having had the fungus isolated prior to transplantation. The prevalence of Aspergillus did not differ between these groups (p = 0.51). Infections with Aspergillus occurred in 4 of the CF recipients (27%) and did not differ from the 3 infections (14%) identified in the non-CF recipients (p = 0.36). However, three of the four infections in the CF recipients involved the healing bronchial anastomosis and occurred prior to postoperative day 60. All three of these recipients had Aspergillus preoperatively. Postoperative infection was more common in the CF recipients having Aspergillus preoperatively than in those CF recipients without preoperative Aspergillus (p = 0.02).

CONCLUSIONS

Isolation of Aspergillus from the LRT following double lung transplantation is common and generally not associated with tissue-invasive disease. Those CF recipients with Aspergillus isolated in cultures of sputum preoperatively are at risk for postoperative infections with this agent. The healing bronchial anastomosis is particularly vulnerable.

Imaging of asthma and allergic bronchopulmonary mycosis

The chest radiograph of the patient with asthma is characterized by bronchial wall thickening and hyperinflation. On CT scanning of patients with asthma one may see airway wall thickening, thickened centrilobular structures, and focal or diffuse hyperlucency. Apparent bronchial dilation may be seen, but the diagnosis of bronchiectasis should be made with caution. Quantification of changes in the airway wall and lung parenchyma may be valuable in understanding the mechanisms of asthma and in evaluating the effects of treatment. Central bronchiectasis occurs in most, but not all, cases of ABPA. Patchy airspace opacity may be the sole radiologic manifestation of ABPA in some cases. Other fungi can rarely cause a similar syndrome. The challenge for the radiologist evaluating the images of a patient with asthma is to find complications, such as ABPA, or alternative diagnoses.

Recurrence of allergic bronchopulmonary aspergillosis in the posttransplant lungs of a cystic fibrosis patient

Cystic fibrosis (CF) is an autosomal recessive disease of exocrine origin. Allergic bronchopulmonary aspergillosis (ABPA) is an immunologic disorder caused by colonization of the airways with Aspergillus fumigatus. A fumigatus has been cultured from posttransplant lungs in CF patients. Colonization of posttransplant lung with Aspergillus is a recognized phenomenon. In this case report, however, we present a patient who developed ABPA both before and after lung transplant. This patient meets the criteria for ABPA based on serologic results. ABPA may be a complication in post-CF lung transplant patients and serologic analysis should be considered when eosinophilia and pulmonary infiltrates or decline in lung function occurs.