Posttransplantation Disseminated Coccidioidomycosis Acquired from Donor Lungs

Abstract

A North Carolinian developed fatal coccidioidomycosis immediately after bilateral lung transplantation. The donor had previously traveled to Mexico, and the recipient had no travel history to an area where Coccidioides immitis is endemic. Immunosuppresive therapy of the transplant recipient likely reactivated latent Coccidioides infection in the donor lungs, leading to posttransplant coccidioidomycosis. CASE REPORTA 61-year-old North Carolina resident with chronic obstructive pulmonary disease and emphysema received a bilateral lung transplant. Subsequent immunosuppressive therapy included methylprednisone, azathioprine, and cyclosporine. During hospitalization, the patient also received cefuroxime, clindamycin, piperacillin-tazobactam, and acyclovir as prophylaxis, but no antifungal prophylaxis was initiated. Posttransplantation, the patient was poorly responsive and had complications, including coagulopathy, hypotension, and hypoxia, resulting in increased oxygen requirements. Laboratory findings were consistent with liver, pancreas, and kidney dysfunction, and the patient ultimately required hemodialysis. Chest X-ray images during the first postoperative week indicated bilateral diffuse pulmonary opacities consistent with edema or infection.At 2 weeks posttransplantation, cerebrospinal fluid (CSF) was obtained. CSF analysis showed Ͻ1 red blood cell/mm 3 and 1 total nucleated cell/mm 3 (22% lymphocytes, 63% monocytes, 15% other cells). The CSF contained 32 mg of protein/dl (normal, 15 to 45 mg/dl). A glucose level determination was not performed. The Gram stain showed no polymorphonuclear leukocytes and no organisms. The CSF culture was reported as no growth at 7 days, and peripheral blood cultures were negative after 5 days of incubation. Bronchial washings from the donor lungs at the time of transplantation grew oxacillin-susceptible Staphylococcus aureus. Stenotrophomonas maltophilia and coagulase-negative Staphylococcus spp. were recovered from subsequent washings. The patient's chest X-ray images showed persistent bilateral infiltrates and worsening alveolar consolidation.During the third week posttransplantation, chest X-ray images demonstrated extensive, progressive bilateral air space and interstitial opacities, as well as bilateral apical and lateral pleural thickening. In addition, a brain magnetic resonance image showed multiple areas of enhancement in the region of the gray-white matter junction thought to be consistent with a fungal infection. The patient had multiple line-drawn blood cultures positive with Candida parapsilosis. Further, a KOH preparation of the patient's bronchial washing showed budding yeast with pseudohyphae, and the Gram stain showed polymorphonuclear leukocytes and yeast. Interestingly, this culture not only grew Candida and S. maltophilia but also Coccidioides immitis. In less than 1 month postoperatively, the patient died, and an autopsy was performed.

Transmission of Tropical and Geographically Restricted Infections during Solid-Organ Transplantation

“…Reports of transmission due to infected donor lungs, liver, and kidneys have been published (249,368,405). In all these cases, coccidioidal infection developed in the early posttransplant period.…”

“…In one report, a patient from North Carolina developed fatal coccidioidomycosis soon after bilateral lung transplantation. The donor had previously traveled to Mexico, and the recipient had no history of travel to an area where C. immitis is endemic (249). Another lung transplant recipient developed fulminant pneumonia in the immediate postoperative period after transplantation.…”

“…Coccidioidomycoses complicating the postoperative course of renal, heart/heart-lung, liver, or small bowel transplant recipients have been reported (32,34,35,43,249,368,405).…”

Transmission of Coccidioidomycosis to a Human via a Cat Bite

“…may infect a wide variety of mammals (dogs, cats, cattle, sheep, swine, equine animals, armadillos, sea lions, and dolphins), as well as some reptiles, although they have not been shown to infect birds (6,10). Transmission of coccidioidomycosis from animals to humans has almost never been reported.…”

“…Except in rare cases, coccidioidomycosis is not thought to spread from person to person in its tissue spherule-endospore phase (5). There have been only a few reports of transmission of coccidioidomycosis by tissue transplantation to recipients from donors harboring the organism and one report of intrauterine transmission during pregnancy (1,6).…”