Successful Treatment of Scedosporium Sinusitis in Two Lung Transplant Recipients: Review of the Literature and Recommendations for Management

Abstract

Background: Scedosporium fungal infection is an emerging disease which is difficult to diagnose and treat. Patients undergoing lung transplant may be colonized prior to transplantation and are at risk for lethal allograft infection after transplantation.

Objectives: To identify and evaluate treatment options.

Methods: This study is a retrospective review of patients treated at a tertiary academic medical center from 2007 to 2017 with positive sinonasal cultures. A review of the literature was also performed to identify additional cases.

Results: Two lung transplant patients had a positive culture for Scedosporium. The literature search resulted in 37 citations, which yielded only 2 prior cases of Scedosporium paranasal sinus colonization or infection in lung transplant recipients. Three of the 4 patients had cystic fibrosis. Two of the patients were colonized before initial transplant, while 1 patient was colonized before subsequent transplant. Three of the 4 patients survived, and all 3 had disease isolated to their sinuses and lungs treated with sinus surgery, while the fourth had disseminated disease and did not undergo sinus surgery. All patients were treated with multiple antifungals due to resistance patterns. One surviving patient cleared both sinus and lung cultures in less than 1 month, while the other 2 surviving patients achieved negative cultures after a minimum of 6 months.

Conclusions: Surgery may be especially important in patients with fungal sinus colonization or infection before or after lung transplantation. Chronic sinusitis is an important source for persistent fungal colonization and reinfection of the allograft which could be removed with surgical debridement before causing highly morbid pulmonary disease.

Keywords: Lomentaspora prolificans, Scedosporium prolificans; Scedosporium apiospermum; cystic fibrosis; endoscopic sinus surgery; inhaled amphotericin; isavulconazole; lung transplantation.

Figure 1.

Coronal CT of sinuses of Patient 1. A, At the time of diagnosis with sinus Scedosporium (note near complete opacification of bilateral maxillary sinuses) and after (B) bilateral medial maxillectomies and Draf IIB procedures with the improvement in aeration and eventual negative cultures.

Figure 2.

Axial magnetic resonance imaging of orbits of Patient 2. A, T1 fat saturated postcontrast at the time of diagnosis with sinus Scedosporium with dashed area highlighting concern for invasion into the retromaxillary space and (B) T1 without contrast 4 months later after right medial maxillectomy with black arrow highlighting area of posterior maxillary wall bone removal.