Aspergillus infections after lung transplantation: clinical differences in type of transplant and implications for management

Invasive pulmonary aspergillosis is an infection seen in patients receiving intensive immunosuppressive regimens, such as transplant recipients. Some risk factors that increase the incidence of infection have been determined, and patients defined as having high risk are recommended to take antifungal prophylaxis and be monitored closely. Here, we present a liver transplant patient with mild respiratory symptoms and a normal chest radiography on day 26 posttransplant. However, he had acute renal failure and underwent hemodialysis, which are both defined to increase significantly the risk of aspergillosis. Although the radiographic scan was initially normal, thorax tomography and later bronchoscopy showed findings compatible with pulmonary aspergillosis, and the patient was started on antifungal treatment. The nonspecific mild symptoms and an initial normal radiology can make diagnosis of invasive fungal infections difficult; thus caution and close follow-up of high-risk patients should be performed. Key words: Antifungal, Aspergillus fumigatus, Pulmonary infection, Renal failure IntroductionInvasive fungal infection, especially aspergillosis, is a matter of concern in immunocompromised patients, particularly solid-organ transplant recipients. The presence of nonspecific and mild symptoms during follow-up in these patients can lead to delay in diagnosis of local and even disseminated infections, which unfortunately increases the overall mortality rates. Case ReportA 46-year-old patient who was diagnosed with cirrhosis underwent a deceased-donor liver transplant. After the procedure, he underwent hemodialysis because of acute renal failure. The patient received high-dose corticosteroids because of acute rejection shown in liver biopsy 10 days later. The patient was consulted for cough and purulent sputum at day 26 posttransplant. His physical examination was unremarkable, and chest radiography showed no obvious infiltration (Figure 1). Treatment with ceftriaxone and clarithromycin was started after screening for possible pathogens, and a thorax tomography was requested. The tomography showed multiple nodular infiltrates in the right upper lobe (Figure 2). Bronchoscopy was planned as inflammation markers did not decrease, and blood galactomannan was found to be positive (0.83).Surprisingly, disseminated white plaques were present in the mucosa of all segments and both main bronchi (Figure 3). Mucosal biopsy and bronchoalveolar lavage were obtained for further investigation. Galactomannan antigen level in the bronchoalveolar specimen was high (6.6). Pathologic examination and culture results together confirmed the fungal infection to be compatible with Aspergillus fumigatus. The patient was started on voriconazole treatment.Bronchoscopy performed 1 week later showed a remarkable regression of the mucosal findings. However, a change in the patient's mental status was detected. Brain magnetic resonance imaging showed nodular lesions compatible with abscess, and liposomal amphotericin B was added to the treatmen...

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“…7,8 As shown in Figure 2, the patient had multiple nodular lesions, especially in the right upper lobe.…”

Section: Discussionmentioning

confidence: 97%

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Esendağlı

Şerifoğlu²,

Bozbas³

et al. 2018

Exp Clin Transplant

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“…Most Aspergillus infections historically occurred within the first year following SOT [20,73,74]. Tracheobronchial and/or anastomotic Aspergillus infections typically occurred within the first 90 days post transplant compared with invasive pulmonary aspergillosis which tended to occur later [73,74].…”

Section: Ifi Timeline: Sotmentioning

confidence: 99%

“…Tracheobronchial and/or anastomotic Aspergillus infections typically occurred within the first 90 days post transplant compared with invasive pulmonary aspergillosis which tended to occur later [73,74]. The majority of experts agree that the risk for IA is substantially high enough immediately following lung transplant to warrant antifungal prophylaxis and American Society of Transplantation guidelines recommend continuing prophylaxis following lung transplantation at least until bronchial anastomosis remodeling is complete [75].…”

Section: Ifi Timeline: Sotmentioning

confidence: 99%

“…In addition, a recent Australian study of candidemia in SOT recipients found that 54% of infections developed greater than 6 months after transplant, the majority of these in renal transplant recipients. Notably, nearly all these patients were hospitalized at the time of diagnosis due to complications from various bacterial infections and had been receiving broadspectrum antibiotics [72].Most Aspergillus infections historically occurred within the first year following SOT [20,73,74]. Tracheobronchial and/or anastomotic Aspergillus infections typically occurred within the first 90 days post transplant compared with invasive pulmonary aspergillosis which tended to occur later [73,74].…”

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confidence: 99%

See 1 more Smart Citation

Fungal Infections in Transplant and Oncology Patients

Person

Kontoyiannis

Alexander

2011

Hematology/Oncology Clinics of North America

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“…Aspergillus, also the commonest affecting 6.2% of all lung transplant recipients (Singh and Husain 2003), may take the form of tracheobronchitis, anastomotic infection of parenchymal invasion, although disseminated disease can also occur. Complicated surgery in addition to immunosuppressive therapy and renal impairment are recognized as risk factors for fungal infection, suggesting that extra vigilance may be warranted in Sarcoidosis patients in the weeks post procedure.…”

Section: Infectionsmentioning

confidence: 99%

Lung Transplantation for Pulmonary Sarcoidosis

Keating¹

2011

Sarcoidosis Diagnosis and Management

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Aspergillus infections after lung transplantation: clinical differences in type of transplant and implications for management

Cited by 264 publications

References 33 publications

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Fungal Infections in Transplant and Oncology Patients

Lung Transplantation for Pulmonary Sarcoidosis

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