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ABSTRACT
Introduction: Lung transplant recipients are at the highest risk of infectious complications among all solid-organ transplant (SOT) recipients. In the current era, many standardized protocols in terms of diagnostic algorithms, prophylaxis, and therapeutic strategies have improved the management of the most common infectious complications. Conversely, diagnosis of rare infections can be particularly challenging and this can delay appropriate treatment.
Areas covered: This article will review the epidemiology, clinical presentation, diagnostic and therapeutic management of certain rarely reported viral, fungal, bacterial and parasitic infections in lung transplant recipients.
Expert opinion: Once the most frequent infections are excluded, clinical suspicion combined with molecular diagnostic methods such as targeted and broad-spectrum PCRs can allow diagnosis of a rare infection. A multidisciplinary team, including transplant pulmonologists, transplant infectious diseases specialists, microbiologists and pathologists is essential for prompt diagnosis and optimal therapeutic management.
Article highlights
Lung transplant recipients are at high risk for infectious complications.
An early surgical site infection without microbiological documentation should evoke difficult-to-culture pathogens, such as Mycoplasma or Ureaplasma.
Progressive lung infiltrates despite antibiotic therapy and without microbiological evidence of aspergillosis should trigger additional investigations for rare fungal or fastidious bacterial infections.
Most uncommon fungal infections and nocardiosis may also have an extra-pulmonary localization, typically a cerebral or cutaneous involvement.
Clinical suspicion combined with molecular diagnostic methods such as multiplex PCRs and next-generation sequencing (NGS) assays can improve diagnosis of rare infections.
Many rare infections require reduction of immunosuppression. Moreover, drug-to-drug interactions between antimicrobial therapy and the immunosuppressive regimen are common.
A multidisciplinary team, including transplant pulmonologists, transplant infectious diseases specialists, microbiologist and pathologists is essential for the management of rare infections.
Abbreviations
| BG: | = | 1,3-β-d-glucan |
| CNI: | = | calcineurin inhibitors |
| CF: | = | cystic fibrosis |
| CT: | = | computed tomography |
| CSF: | = | cerebrospinal fluid |
| CMV: | = | cytomegalovirus |
| EBV: | = | Epstein-Barr virus |
| GM: | = | Galactomannan |
| HEV: | = | hepatitis E virus |
| HHV-8: | = | human Herpes virus-8 |
| HSV: | = | herpes simplex virus |
| IHS: | = | idiopathic hyperammonemia syndrome |
| IRIS: | = | immune reconstitution inflammatory syndrome |
| KS: | = | Kaposi’s Sarcoma |
| MCC: | = | Merkel cell carcinoma |
| MCD: | = | multicentric Castleman disease |
| NGS: | = | next-generation sequencing |
| PEL: | = | primary effusion lymphoma |
| PML: | = | multifocal leukoencephalopathy |
| PTLD: | = | post-transplant lymphoproliferative disorders |
| S/L: | = | Scedosporium apiospermum and Lomentospora prolificans |
| SOT: | = | solid organ transplant |
| TMP‐SMX: | = | trimethoprim‐sulfamethoxazole |
| TS: | = | trichodysplasia spinulosa |
| VZV: | = | varicella-zoster virus |
Declaration of interest
O Manuel discloses research grants from Lophius Biosciences. The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
Reviewer disclosures
Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.