Blastomyces dermatitidis in a Renal Transplant Recipient: A Case Report

Clinical Characteristics and Outcomes of Endemic Mycoses After Solid Organ Transplantation: A Comprehensive Review

Background

Geographically endemic fungi can cause significant disease among solid organ transplant (SOT) recipients. We provide an update on the epidemiology, clinical presentation, and outcomes of 5 endemic mycoses in SOT recipients.

Methods

Multiple databases were reviewed from inception through May 2023 using key words for endemic fungi (eg, coccidioidomycosis or Coccidioides, histoplasmosis or Histoplasma, etc). We included adult SOT recipients and publications in English or with English translation.

Results

Among 16 cohort studies that reported on blastomycosis (n = 3), coccidioidomycosis (n = 5), histoplasmosis (n = 4), and various endemic mycoses (n = 4), the incidence rates varied, as follows: coccidioidomycosis, 1.2%-5.8%; blastomycosis, 0.14%-0.99%; and histoplasmosis, 0.4%-1.1%. There were 204 reports describing 268 unique cases of endemic mycoses, including 172 histoplasmosis, 31 blastomycosis, 34 coccidioidomycosis, 6 paracoccidioidomycosis, and 25 talaromycosis cases. The majority of patients were male (176 of 261 [67.4%]). Transplanted allografts were mostly kidney (192 of 268 [71.6%]), followed by liver (n = 39 [14.6%]), heart (n = 18 [6.7%]), lung (n = 13 [4.9%]), and combined kidney-liver and kidney-pancreas (n = 6 [2.7%]). In all 5 endemic mycoses, most patients presented with fever (162 of 232 [69.8%]) and disseminated disease (179 of 268 [66.8%]). Cytopenias were frequently reported for histoplasmosis (71 of 91 [78.0%]), coccidioidomycosis (8 of 11 [72.7%]) and talaromycosis (7 of 8 [87.5%]). Graft loss was reported in 12 of 136 patients (8.8%). Death from all-causes was reported in 71 of 267 (26.6%); half of the deaths (n = 34 [50%]) were related to the underlying mycoses.

Conclusions

Endemic mycoses commonly present with fever, cytopenias and disseminated disease in SOT recipients. There is a relatively high all-cause mortality rate, including many deaths that were attributed to endemic mycoses.

Invasive Fungal Diseases in Africa: A Critical Literature Review

Invasive fungal diseases (IFDs) are of huge concern in resource-limited settings, particularly in Africa, due to the unavailability of diagnostic armamentarium for IFDs, thus making definitive diagnosis challenging. IFDs have non-specific systemic manifestations overlapping with more frequent illnesses, such as tuberculosis, HIV, and HIV-related opportunistic infections and malignancies. Consequently, IFDs are often undiagnosed or misdiagnosed. We critically reviewed the available literature on IFDs in Africa to provide a better understanding of their epidemiology, disease burden to guide future research and interventions. Cryptococcosis is the most encountered IFD in Africa, accounting for most of the HIV-related deaths in sub-Saharan Africa. Invasive aspergillosis, though somewhat underdiagnosed and/or misdiagnosed as tuberculosis, is increasingly being reported with a similar predilection towards people living with HIV. More cases of histoplasmosis are also being reported with recent epidemiological studies, particularly from Western Africa, showing high prevalence rates amongst presumptive tuberculosis patients and patients living with HIV. The burden of pneumocystis pneumonia has reduced significantly probably due to increased uptake of anti-retroviral therapy among people living with HIV both in Africa, and globally. Mucormycosis, talaromycosis, emergomycosis, blastomycosis, and coccidiomycosis have also been reported but with very few studies from the literature. The emergence of resistance to most of the available antifungal drugs in Africa is yet of huge concern as reported in other regions. IFDs in Africa is much more common than it appears and contributes significantly to morbidity and mortality. Huge investment is needed to drive awareness and fungi related research especially in diagnostics and antifungal therapy.

Reactivation of latent infections in solid organ transplant recipients from sub-Saharan Africa: What should be remembered?

International migration from Sub-Saharan African countries to the European Union and the United States has significantly increased over the past decades. Although the vast majority of these immigrants are young and healthy people, a minority can be affected by chronic conditions eventually leading to solid organ transplantation (SOT). Importantly, these candidates can bear geographically restricted fungal and parasitic latent infections that can reactivate after the procedure. An appropriate evaluation before transplantation followed by treatment, whenever necessary, is essential to minimize such risk, as covered in the present review. In short, infection due to helminths (Schistosoma spp. and Strongyloides stercoralis) and intestinal protozoa (Entamoeba histolytica, Giardia lamblia or Cyclospora cayetanensis) can be diagnosed by multiple direct stool examination, serological assays and stool antigen testing. Leishmaniasis can be assessed by means of serology, followed by nucleic acid amplification testing (NAAT) if the former test is positive. Submicroscopic malaria should be ruled out by NAAT. Screening for Histoplasma spp. or Cryptococcus spp. is not routinely indicated. Consultation with an Infectious Diseases specialist is recommended in order to adjust preemptive treatment among Sub-Saharan African SOT candidates and recipients.

Successful Treatment of Cutaneous Blastomycosis in a Renal Transplant Patient With BK Virus Infection: A Case Report

This is the first case report from Turkey to describe a renal transplant complicated by subcutaneous blastomycosis and BK infection. The cutaneous lesions were successfully treated with amphotericin B and fluconazole. The presence of BK infection led to graft failure. Infections with uncommonly seen organisms should be kept in mind due to the impaired T-cell immunity in transplantation.