Viral and fungal infections after liver transplantation — Part II

Abstract

Viral and fungal infections in liver transplant recipients are important to recognize and treat early because of their association with substantial morbidity and mortality. Some viruses, such as cytomegalovirus and human herpesvirus 6, have immunomodulatory properties and can facilitate other infections, including fungal infections. Cytomegalovirus has long been recognized as an important virus in transplantation, but in the past decade other viruses have also received attention in the medical literature because of their association with particular clinical syndromes. Although human herpesvirus 6 has been associated with fever, rash, and encephalitis, a direct cause-and-effect relationship is still lacking. Human herpesvirus 8 has been found to be the cause of Kaposi sarcoma. Molecular techniques (e.g., pp65 antigenemia and polymerase chain reaction) that have been introduced for routine diagnosis of viruses have facilitated the diagnosis of asymptomatic viral infections and the institution of preemptive therapy. Nonetheless, the diagnosis of invasive fungal infections in liver transplant recipients is often delayed and thus associated with high mortality. Despite the use of new antifungal agents in clinical practice and the reduced incidence of fungal infections because of antifungal prophylaxis regimens, mortality has not decreased. Future patient outcomes may improve with early identification of patients who have risk factors for invasive fungal infections and with the development of new molecular diagnostic techniques for early detection. Liver Transpl 12: 2-11, 2006.

Infections After Orthotopic Liver Transplantation

“…Inhalation of fungal spores (which have been associated with bird defecation) can results in a possible symptomatic pneumonia or asymptomatic infection often with dissemination to other body sites, most commonly the central nervous system. 46 In a recent case series: infected patients had pneumonia only (46%), meningitis only (36%), dissemination to multiple distant organs (11%), or involvement of another single organ (e.g., lymph node) (7%). Symptoms developed a mean of 30 months (range, 1-146 months) after transplantation with a mortality rate of 25%.…”

“…[46][47][48] Risk factors for invasive candidiasis include the use of prophylactic antibiotics to prevent spontaneous bacterial peritonitis, the need for renal replacement therapy (hemodialysis) postoperatively, and retransplantation. 44 Other potential risk factors include technically complicated and lengthy transplantation operative procedures, intraoperative transfusion, prolonged ICU admission, repeated intra-abdominal surgery after transplantation, Candida colonization, and cytomegalovirus disease.…”

“…87 The risk of acquiring CMV infection or disease after transplantation can be stratified by the serologic status of the donor and the recipient. 46 The highest risk of developing CMV infection occurs in the seronegative recipient (R) of an organ from a seropositive donor (D) (referred to as D+/RÀ). CMV infection will eventually develop in most recipients in this category and a high percentage of them will become symptomatic.…”

“…It frequently causes subclinical infection and a majority of the population is seropositive by adolescence. 46 Of the two recognized variants of HHV-6 (A and B), variant B is believed to be the cause of most infections in transplant recipients, principally by reactivation of the virus 2-8 weeks after transplantation. HHV-6 incidence in liver transplant recipients varies from 14 to 82%.…”

Hepatobiliary Quiz Answers—19 (2016)

“…Need of hemodialysis post-operatively, prophylaxis for spontaneous bacterial peritonitis, and retransplantation are important risk factors for invasive candidiasis. 61,62 Cytomegalovirus (CMV) infections are common in post-OLT patients. Patients who develop CMV disease are at a higher risk for invasive candidal infections.…”