Brain Abscess in Solid Organ Transplant Recipients Receiving Cyclosporine-Based Immunosuppression

Abstract

Objective-To determine the incidence, clinical presentation, and outcome and confounding factors associated with the development of a brain abscess in solid organ transplant recipients.Design-A 14-year retrospective survey.Setting-A single, multiorgan, academic transplantation center.Patients-A total of 2380 liver transplant recipients, 1650 kidney transplant recipients, and 598 heart, heart-lung, or lung transplant recipients of all ages (pediatric and adult) were included. All patients were given cyclosporine-based immunosuppression during this period.Main Outcome Measure-A brain abscess was determined to be present if there was histological and/or microbiological confirmation of a brain lesion seen by a computed tomographic scan. A brain abscess was considered suspicious if radiographic findings were seen in the clinical setting of neurologic symptoms and fever without histological or microbiological confirmation.Results-A brain abscess developed in a total of 28 patients (0.61%) of the total study population. The frequency of brain abscess according to organ type was as follows: 0.63%, liver; 0.36%, kidney; and 1.17%, heart and heart-lung. The overall mortality was 86%. Complicating factors associated with fungal (Candida and Aspergillus sp) abscess formation included major subsequent operations, retransplantations, antirejection therapy, associated bacteremia or viremia, and multiorgan failure. The lung was the primary site of dissemination in 18 patients. Low-dose prophylactic amphotericin was ineffective in preventing a fungal brain abscess in 10 high-risk patients. Because of the ineffective therapy and the deadly nature of established fungal abscesses, full-dose antifungal therapy and reduced immunosuppression were warranted on identification of a high-risk clinical setting. Nonfungal abscesses (Nocardia and Toxoplasma sp) occurred in healthy graft recipients long after transplantation. The existing medical therapy is usually effective in these patients, provided that rapid tissue diagnosis is established. Conclusion-The epidemiological features of brain abscess formation after solid organ transplantation suggest 2 populations of patients exist that differ in timing, clinical setting, and response to therapy. For the chronically immunosuppressed outpatient, an established abscess should be empirically treated with sulfonamides until tissue diagnosis is confirmed. On the other hand, the acutely immunosuppressed posttransplant recipient, with defined risk factors, should receive full-dose therapy with amphotericin B and concomitantly lowered immunosuppression.

Bacterial Meningitis in Patients using Immunosuppressive Medication: a Population-based Prospective Nationwide Study

“…These patients were not included in our cohort. As the use of immunosuppressive medication is a risk factor for brain abscess, we could have missed cases of bacterial meningitis in patients use of immunosuppressive medication (Selby et al 1997).…”

AspergillusInfections in Transplant Recipients

“…Aspergillus infections in these patients typically occur in the early posttransplant period. The median time to onset after transplantation was 17 days in one study (290) and 16 days in another (283). A vast majority of the patients who developed invasive aspergillosis had never left the intensive care unit after liver transplantation surgery (30,290).…”

Invasive Aspergillosis in Solid Organ Transplant Recipients

“…Historically, invasive aspergillosis in liver transplant recipients has occurred in the early posttransplant period; the median time to onset after transplantation was 17 days in one study (2) and 16 days in another (16) (2,6,10).…”