Coccidioidomycosis in Liver Transplant Recipients in an Endemic Area

Abstract

Coccidioidomycosis is an infection caused by Coccidioides species, which are endemic for the Southwestern United States and parts of Central America and South America. Most infected individuals are asymptomatic or have mild-to-moderate respiratory illness. Coccidioidomycosis is more severe in patients with depressed cellular immunity, such as organ transplant recipients. We retrospectively reviewed charts of 391 liver transplant recipients (mean follow-up, 38.7 months; range, 2-105 months). Before transplantation, 12 patients had a history of coccidioidomycosis and 13 patients had asymptomatic seropositivity. Of these 25 patients, 23 had no active coccidioidomycosis posttransplantation and 2 had reactivated infection. One of 5 patients with indeterminate serology before transplantation died of disseminated coccidioidomycosis shortly after transplantation. De novo coccidioidomycosis developed in 12 patients (3%) who had no evidence of coccidioidomycosis pretransplantation. Of 15 total episodes of posttransplantation coccidioidomycosis, 10 (66%) occurred during the first year. Dissemination was noted in 33% of active coccidioidomycosis after transplantation; two patients (13%) died of coccidioidomycosis. Because most coccidioidal infections occurred in the first posttransplantation year despite targeted antifungal prophylaxis, we recommend a new strategy of universal antifungal prophylaxis for 6-12 months for liver transplant recipients who reside in the endemic area.

Donor-Derived Fungal Infections in Organ Transplant Recipients: Guidelines of the American Society of Transplantation, Infectious Diseases Community of Practice

“…Coccidioidomycosis occurs in 1.5-8.7% of the transplant recipients in endemic areas, typically in the first posttransplant year (81). Several cases of donor-derived coccidioidomycosis in transplant recipients have been reported (49,(82)(83)(84)(85)(86)(87)(88)(89)(90) (92). Further assessment to define the presence of extrapulmonary infection may be warranted in such instances, with particular attention to the CNS, cutaneous and osteoarticular infections.…”

“…Fluconazole and itraconazole have proven to be efficacious for prophylaxis of coccidioidomycosis in transplant recipients (93)(94)(95) and both have been used for the prevention of donor-derived coccidioidomycosis (82,85) (Tables 5 and 6). Suggested regimens are fluconazole (400 mg daily) or itraconazole (200 mg twice daily) (82,85).…”

Recent Advances in Our Understanding of the Environmental, Epidemiological, Immunological, and Clinical Dimensions of Coccidioidomycosis

“…Excellent data summaries and recommendations for management of coccidioidomycosis in transplant patients have been published (94,174). Screening through serology, culture of organs, and chest radiography are recommended for donors residing in the region of endemicity.…”

“…Coccidioidal infection can also be acquired de novo after transplantation. The spectrum of illness in transplant patients resembles that in immunocompetent hosts, but disseminated infection appears to be more common (174). At one center in the area of endemicity, transplant patients with asymptomatic seroconversion are carefully monitored but are not always treated with antifungal therapy (94).…”

Infections After Orthotopic Liver Transplantation

“…Post transplantation, de novo or reactivated infection can occur with systemic immunosuppression as well. 76 …”