Coccidioidomycosis in solid organ transplant recipients

Abstract

Purpose of reviewThe purpose of the review is an update of diagnosis and treatment of coccidioidomycosis infection in solid organ transplant (SOT) patients. Endemic fungal infections continue to be a cause of serious morbidity and mortality in transplant recipients. Recent findingsIn transplant patients there are recommendations regarding screening in areas that are endemic for coccidioidomycosis. This screening involves serologic testing and chest imaging. In endemic areas pretransplant seropositivity varies from 1.4 to 5.6%. In immunocompromised patients with elevated complement fixation titers, evaluation of cerebrospinal fluid is recommended even in the absence of symptoms. Although coccidioidomycosis can be a self-limited disease in immunocompotent patients, all SOT patients should be treated regardless of severity. This may include intravenous amphotericin B in severe cases and fluconazole therapy in milder episodes. In those SOT recipients with evidence of prior coccidioidomycosis, lifelong secondary prophylaxis with fluconazole given risk of recurrent disease.

Fungal Infections in Liver Transplant Recipients

“…Histoplasma species and Blastomyces species are endemic to the Ohio and Mississippi River Valleys, and Coccidioides species are endemic to the southwestern states [ 73 , 74 , 75 , 76 ]. Outside these regions, cases may represent remote travel, reactivation, or donor-derived infection particularly within the first month after transplantation [ 75 , 77 ].…”

“…Presentation ranges from indolent pulmonary infection to acute respiratory distress syndrome (ARDS) and extrapulmonary dissemination to the skin, osteoarticular system, CNS, and genitourinary system [ 75 ]. SOTRs are at increased risk of severe disease, dissemination, and death [ 75 , 76 , 78 , 79 ]. The rates of dissemination in SOTRs were 81% for histoplasmosis [ 79 ], 75% for coccidioidomycosis [ 77 ], and 37.5% for blastomycosis in [ 78 ].…”

“…The EIA antigen tests are specific for endemic mycosis, but there is significant cross-reactivity between histoplasmosis and blastomycosis [ 74 ]. Although serologic studies are less reliable for immunosuppressed SOTRs, the highly sensitive coccidioidomycosis EIAs for IgM and IgG are used for screening, and results are confirmed with a more specific and quantitative complement fixation test [ 76 ].…”

“…Mortality inclusive of all endemic mycoses in the TRANSNET study was 16% [ 73 ]. In separate cohorts, mortality was 10% for histoplasmosis [ 79 ], 30–50% for coccidioidomycosis [ 76 , 87 ], and 21.2% for blastomycosis [ 78 ]. The risk of death from histoplasmosis was associated with increased age, severe disease, fungemia, and higher urine antigen [ 79 ].…”

Coccidioidomycosis in Allogeneic Stem Cell Transplant Recipients: Case Series and Review of the Literature

“…This assessment starts with a detailed travel history. Patients who have traveled to or have resided in a Coccidioides -endemic region should undergo serologic Coccidioides testing by EIA, ID, and CF [ 32 , 33 , 34 ]. If serologies are negative and the patient continues to reside in or travel to a Coccidioides -endemic region, it may be prudent to initiate coccidioidomycosis-specific prophylaxis.…”