PURPOSE: Coccidioides species commonly cause pneumonia in endemic areas. In immunosuppressed patients, the risk of severe disease increases. Incidence of infection in solid organ transplant recipients has been reported as 1-2%.¹ The burden of disease in lung transplant recipients is unknown.
METHODS: Retrospective chart review was undertaken on 105 bilateral lung transplant recipients (out of 212 total lung recipients) between 1993 and 2009. Subjects were reviewed for pre- and post-transplant evidence of coccidioidomycosis and grouped as "probable" or "definite" infection based on clinical course, serology, cytopathology, and culture.
RESULTS: 6.7% of patients developed coccidioidomycosis post-transplant. All subjects but one was grouped as "definite" based on identification of organism in pulmonary secretions or skin biopsy. Of those with post transplant coccidioidomycosis, 70% had received prophylaxis. All instances of post-transplant infection occurred within 12 months of transplantation. One donor lung grew Coccidioides and was transplanted prior to final culture result availability. The patient received treatment and did not become ill. A second donor had positive serology (IgM). The recipient died on the date of transplantation. Despite active infection, serology was negative in all confirmed post-transplant cases. Six subjects had a history of coccidioidomycosis pre-transplantation. None developed post-transplant coccidioidomycosis and all received prophylaxis active against Coccidioides.
CONCLUSION: The overall infection rate has historically been estimated at 3% per year.² In our patient population the incidence of disease was 6.7% in the first post-transplant year. Coccidioidal serology is less useful diagnostically in the setting of lung transplantation than in published series of community acquired infection. Although the early time course to infection is compatible with reactivation of disease, reinfection or unrecognized donor related transmission of Coccidioides is also plausible. Knowledge of the serostatus of donors from the endemic area is speculated to be helpful.
CLINICAL IMPLICATIONS: The risk of coccidioidomycosis post bilateral lung transplantation is significant. Negative serology does not exclude serious infection in these patients. Prophylaxis for patients with a documented history of coccidioidomycosis is warranted.
DISCLOSURE: Sachin Chaudhary, No Financial Disclosure Information; No Product/Research Disclosure Information