Mucormycosis in lung transplant recipients: A systematic review of the literature and a case series

Abstract

Background Mucormycosis is a rare infection in lung transplant recipients (LTR). Our objective was to better define the clinical presentation and optimal management of this frequently lethal infection. Methods A systematic review of the literature was performed to identify all published cases of mucormycosis in LTR using PubMed/MEDLINE. These cases were analyzed together with a new case series from our clinic. Results Literature search yielded 44 articles matching the inclusion criteria, describing 121 cases. Six additional cases were identified from our clinic. Data regarding infection site and outcome were available for a total of 53 patients. The lungs were the most common site of infection (62%), followed by rhinocerebral and disseminated disease. Most cases (78%) developed in the first post‐transplant year, with over 40% of them in the first month. Additional risk factors for mucormycosis were identified in over half of the patients. Surgical debridement was uncommon in pulmonary infection (9%). Posaconazole therapy was used in 35% of cases, mostly in combination with amphotericin B. Overall mortality was 32% but varied according to site of infection. Conclusion Mucormycosis in LTRs tends to be an early post‐surgical infection, associated with additional risk factors and intensified immunosuppressive states, and most often affects the lungs, where surgical debridement is rarely feasible. Posaconazole as first‐line therapy should be further explored.

Evaluation of MucorGenius® mucorales PCR assay for the diagnosis of pulmonary mucormycosis

“…Here, we were unable to draw any reliable conclusions concerning the incidence of Aspergillus and mucorales coinfections due to the limitations inherent to the retrospective design of the study, Remarkably, three of five SOT patients with positive mucorales PCR were lung transplant recipients, underscoring the high vulnerability of these patients, whose previous lung dysfunction allowed mucorales colonization, and the rapid onset of infection after transplantation (41).…”

Impact of COVID-19-associated Mucormycosis in Kidney Transplant Recipients: A Multicenter Cohort Study.

“…Interestingly, our report had comparatively lesser mortality (26.7% versus 44%) than the general patients. 30 This can be explained by a high number of ROCM cases in our study, which were detected early by dedicated transplant teams. Furthermore, we had no disseminated disease or cunninghamella species which have previously shown to be associated with higher fatality.…”

“…In a recent meta-analysis of lung transplants (n = 121), the reported mortality was 41%, and the combination of surgical intervention along with antifungal resulted in lesser deaths. 30 In KTR acquiring mucormycosis, a meta-analysis (n = 174) reported a survival rate of 70.02% with antifungal and surgery combination compared to 30% survival in medical therapy alone. 18 Delay in starting antifungal agent has been shown to increase the mortality in mucormycosis.…”

Fungal Infection in Lung Transplantation

“…Mucormycosis most commonly presents as pulmonary disease, although rhinocerebral, disseminated, anastomotic, gastrointestinal, and cutaneous manifestations have all been described. 59 The diagnosis is challenging, as noninvasive studies such as galactomannan and β-1,3-D-glucan and fungal blood cultures are classically negative for these organisms even in the presence of invasive disseminated disease. The possibility of mucormycosis should be considered in clinical scenarios suspicion of fungal infections especially when the host is receiving antifungal prophylaxis that is not active against this group of organisms (such as prophylaxis with fluconazole, itraconazole, or voriconazole).…”

“…The diffuse nature of pulmonary disease due to mucormycosis that is seen after lung transplantation may limit the options for surgical resection. 59 Poor outcomes in lung transplant recipients due to mucormycosis are attributed to rapid vascular invasion, necrosis, and destruction of tissues. Mortality due to mucormycosis is upward of 96% when disseminated but lower in localized pulmonary disease (76%).…”