Fungal Infections After Lung Transplantation

Abstract

Infection remains a significant source of morbidity and mortality after lung transplant, including fungal infection. Various antifungal prophylactic agents are administered for a variable duration after transplant with the goal of preventing invasive fungal infections. Alternatively, some programs target the use of antifungal agents only in those colonized with Aspergillus spp. Despite prophylaxis or preemptive therapy, a significant number of invasive fungal infections occur after lung transplant. Risk factors for fungal infections include single lung transplant, pretransplant Aspergillus colonization, environmental risks, structural lung disease such as cystic fibrosis, augmented immunosuppression, sinus disease, and use of indwelling airway stents.

Keywords: Fungal infection; Fungal prophylaxis; Lung transplantation; Solid organ transplantation.

Fig. 1

Fungal anastomotic infection. Example of anastomotic dehiscence after single left lung transplant with associated positive bronchial culture for Zygomycetes. This 66-year-old male transplant recipient presented with noisy breathing and fall in spirometry 6 weeks after transplant. (A) Shows the chest radiograph with left bronchial irregularity and subcutaneous emphysema. (B) Shows the CT chest with air outside the bronchial tree and subcutaneous emphysema. (C) Demonstrates the findings at bronchoscopy of left bronchial anastomotic dehiscence with visible sutures. Patient responded to liposomal amphotericin B therapy and was converted to lifelong posaconazole therapy. The airway stenosed as it healed and the patient eventually required endoscopic balloon and silicone stent placement in the left airway.

Fig. 2

Aspergilloma. Asymptomatic, 67-year-old man presents 6 months after right single lung transplant for α₁-antitrypsin deficiency with a new native lung nodule. This was found to be an aspergilloma on resection.

Fig. 3

Complicated postoperative bacterial and fungal pleural space infection. A 45-year-old woman with bilateral lung transplant for cystic fibrosis. At the time of transplant, the native lung apices were fused to the chest wall and diseased such that complete excision was not possible. The patient developed complicated, multiorganism pleural space infection with Mycoplasma salivarium, Pseudomonas aeruginosa, C albicans, and Aspergillus fumigatus spp. (A) Chest CT 9 days postoperative. (B) Chest CT 15 days postoperative.

Fig. 4

Central nervous system aspergillosis. A 61-year old man 11 months post–lung transplant presented with right sided headache, double vision, and conjunctivitis. Head imaging demonstrated a right orbital mass. Biopsy demonstrated necrosis, inflammation, and numerous invading narrow-septate hyphae. Cultures grew Aspergillus fumigatus. Patient was treated with liposomal amphotericin B, followed by caspofungin and voriconazole, then ultimately lifelong posaconazole therapy.