Reactivation of Coccidioidomycosis Despite Antifungal Prophylaxis in Solid Organ Transplant Recipients

Abstract

Antifungal prophylaxis effectively suppressed recrudescent coccidioidomycosis after solid organ transplantation for the large majority of patients with a history of coccidioidomycosis before transplantation. Strict lifelong adherence to antifungal prophylaxis is imperative.

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

“…Patients with active disease or a recent history (1 to 2 years) of disease are treated with antifungal therapy, with the dose and duration depending on the severity and timing of the infection. However, reactivation of pretransplant coccidioidomycosis has occurred despite antifungal therapy (175). Coccidioidal infection can also be acquired de novo after transplantation.…”

“…Corticosteroid use is a recognized risk factor for severe coccidioidomycosis (175), as is the administration of tumor necrosis factor inhibitors as described above. The incidence of infection may not be greater than that in the general population of the area of endemicity, but the risk of dissemination seems to be greater.…”

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

“…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).…”

Antifungal therapeutics for dimorphic fungal pathogens

“…Elimination of symptoms has been assumed to indicate clearance of the infection, but evidence is now suggesting that at least in some individuals, the infection can enter a latent state, which can re-emerge later when the balance between pathogen and host immunity is altered (e.g., immunosuppression of the host). [50][51][52][53][54][55][56] Since inhalation is the route of exposure, mycoses caused by dimorphic fungal pathogens are initially pulmonary diseases. In immunocompetent individuals, mild disease is mostly subclinical, often going undiagnosed.…”