COPD

Be vigilant for cryptococcal infection in lung transplant patients


Immunosuppression and environmental exposures mean that cryptococcal infection is an ongoing risk for lung transplant recipients, according to the authors of a major case series from Victoria.

Already known to be one of the most common invasive fungal infections in solid organ transplant recipients, cryptococcosis was also recorded in eleven of 800 recipients of lung transplants for conditions such as COPD, IPF and CF between 2012 and 2017 at the Alfred Hospital in Melbourne, a retrospective review found.

Most of the cases were asymptomatic, had no dissemination and were detected by routine post-transplant surveillance BAL with positive Cryptococcus culture. However, two cases had more serious CNS involvement, one with pulmonary and CNS infection and one with isolated CNS infection, the review published in Transplant Infectious Disease showed.

Both these cases presented with headache, and brain imaging showed cerebral oedema, myelinosis and leptomeningeal enhancement. One of the patients died after rapid deterioration.

As with cryptococcosis seen in solid organ transplants, most cases had a diagnosis late after transplantation (median 233 days).

The report authors note that most patients had an identifiable source of  exposure to cryptococcal infection, which included living on a farm, soil exposure, exposure to eucalypt/gum trees, chopping or burning wood, bushwalking and contact with birds such as pigeons and budgies.

They added that immunosuppression was a well documented risk factor for cryptococcal infection, noting that patients were taking a mean daily dose of prednisolone of 12mg/kg.

“This study represents one of the largest cases series evaluating Cryptococcus infection in lung transplant recipients … [it] highlights the fact that cryptococcal infection should remain a consideration in asymptomatic lung transplant recipients, especially in the presence of non-specific nodules on chest imaging, and that the presence of headache in these patients requires urgent investigation for cryptococcal CNS infect ion,” they concluded.

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