Transplant Complications: Infectious Diseases

Transplant Complications: Infectious Diseases

Debra Dumas-Hicks, RN, BS, CCTC, CCTN

Fawn Fitzmorris, RN, CCTC

Cynthia Cassidy, RN, BSN, CCTC

Karýn Ryan Canales, RN, BSN, CCTC


A. Solid organ transplantation (SOT) has been established as an accepted therapy for end-stage disease of the kidneys, liver, heart, and lungs for nearly 30 years. When infection occurs after SOT, early and specific diagnosis and rapid and aggressive treatment are essential to good clinical outcomes.1

  • Recognition of infection is challenging in transplant recipients as presentation is often complicated by noninfectious causes of fever, such as drug interactions or graft rejection.

  • As a result of the growing population of immunosuppressed patients with prolonged survival, an increased incidence and spectrum of opportunistic infections has been observed.

  • Guidelines for the diagnosis and treatment of infection in transplant recipients have been developed.2

  • While there is general agreement on the major infections for which routine screening is performed, centers vary in the extent of infectious disease investigation and the actions taken as a result of those investigations.3


A. Key Points

  • The successful outcome of SOT requires the careful selection of transplant recipients through a process of medical evaluation and screening.

  • The identification of active and latent infection, along with the optimization of treatment, is an important role of the transplant specialist.

  • Early identification of risk factors that predispose transplant candidates to infection and prompt referral to an experienced infectious diseases (ID) specialist when indicated can prevent posttransplant infections and improve patient outcomes.

B. Goals of Pretransplant Screening

  • Identify conditions that may indicate a contraindication to transplantation.

  • Treat active infection in the pretransplant phase, as clinically indicated.

  • Recognize the risk of posttransplant infection and develop strategies for prophylaxis.

  • Implement preventative measures, including updating immunizations.

C. History Review

  • Childhood infections such as measles, mumps, chickenpox, mononucleosis

  • Underlying illness causing organ failure including, but not limited to, cystic fibrosis (respiratory failure), hepatitis C virus (HCV cirrhosis/liver failure)

  • Adulthood infections that can include the following:

    • Hepatitis B virus (HBV) and hepatitis C virus (HCV)

    • Human immunodeficiency virus (HIV)

    • Tuberculosis (TB)

    • Sexually transmitted diseases

    • Endemic mycoses (histoplasmosis, blastomycosis, coccidioidomycosis)

    • Recurrent infections (e.g., urinary tract, pneumonia, staphylococcal skin soft tissue infection, line-related infections)

  • Concurrent/nosocomial infections such as

    • Urinary tract infection

    • Pneumonia

    • Peritonitis

    • Wound infection

    • Occult abscess

    • Catheter/ventricular assist device-related infection

  • Immunizations

  • Travel history

  • Social risk factors such as

    • Alcohol/drug abuse

    • Incarceration

    • High-risk sexual behavior

      • Lack of contraceptive barrier use

      • Multiple sex partners

    • Tattoos

    • Body piercings

    • Socioeconomic challenges

      • Limited health care access

      • Poverty

      • Language barriers

      • Low health literacy

  • Environmental exposure such as industrial chemicals, cigarette smoke

  • Nutritional practices such as the following:

    • Unsafe source of drinking water

    • Consumption of raw/undercooked meat, unpasteurized dairy products, seafood

  • Allergies to antimicrobial agents

  • See Table 5-1 for Pretransplant Diagnostic Tests and Team Evaluations

TABLE 5-1 Infectious Disease Evaluation

Physical examination

Nutritional status: cachexia, obesity, integumentary (skin lesions)

Eyes, ears, nose, throat

Respiratory (rales, rhonchi, breath sounds)

Cardiac (rub, murmur, endocarditis)

Gastrointestinal (diarrhea, bleeding, ulcers)

Genitourinary (prostate examination, Papanicolaou test)

Blood work

Complete blood cell count with differential leukocyte count

Complete metabolic panel

Cytomegalovirus IgG and IgM antibodies

Toxoplasma gondii IgG and IgM antibodies

Herpes simplex virus I and II IgG and IgM antibodies

Varicella zoster titers

Epstein-Barr virus IgG and IgM antibodies

Serologic screening for syphilis (rapid plasma reagin test)

Human immunodeficiency virus (HIV) 1 and 2

Hepatitis A, B, and C

Lyme titers (if indicated)

Glycosylated hemoglobin (if indicated)


Chest radiograph

Computed tomography scan (if indicated)

CT scan of paranasal sinuses (particularly for patients with cystic fibrosis or a history of recurrent sinus infections)

Abdominal ultrasound

Tuberculin skin test

Quantiferon gold lab

Urinalysis and urine culture

Stool culture (if indicated)

Stool for ova and parasites (if indicated)

Dental screening


Heart transplantation: Toxoplasma gondii IgG and IgM antibodies

Lung transplantation: Sputum cultures to detect colonization of respiratory tract by Aspergillus species, Burkholderia cepacia

From Fischer SA, Lu K. Screening of donor and recipient in solid organ transplantation. Am J Transplant. 2013;13(suppl 4):9-21; Danziger-Isakov L, Kumar D. Vaccination in solid organ transplantation. Am J Transplant. 2013;13(suppl 4):311-317; Ison MG, Grossi P. Donor-derived infections in solid organ transplantation. Am J Transplant. 2013;13(suppl 4):22-30; Ison MG, Nalesnik MA. An update on donor-derived disease transmission in organ transplantation. Am J Transplant. 2011;11:1123-1130; Greenwald MA, Kuehnert MJ, Fishman JA. Infectious disease transmission during organ and tissue transplantation. Emerg Infect Dis. 2012;18(8):e1.


A. Key Points4

  • Transplant candidates and recipients are at increased risk of infectious complications due to end-organ failure and immunosuppression.

  • Every effort should be made to immunize patients in the early phase of disease because the response to many vaccines is diminished in organ failure.

  • Transplant recipients may have a suboptimal response to vaccinations due to their immunosuppressed status; therefore, it is critical to update immunizations prior to transplantation.

  • The ideal time to give vaccines following transplantation is unknown; however, most centers restart vaccinations approximately 3 to 6 months posttransplant.

B. Recommended Pretransplant Immunizations4

  • Adult Candidates

    • Influenza (administered yearly posttransplantation: inactive vaccine only)

    • Hepatitis B:

      • Assess before and monitor after transplant

      • Administer booster if titers fall below 10 IU/L5

    • Hepatitis A (liver transplant candidates or patients at high risk for exposure)

    • Tetanus

    • Pertussis (Tdap) if no tetanus booster in last 10 years

    • Inactive polio

    • Pneumococcal

    • Meningococcal, especially for

      • Military personnel

      • Travelers to high-risk areas

      • Postsplenectomy patients

      • College freshmen living on campus

    • Rabies (exposure or potential exposures due to vocations only)

    • Human papillomavirus (HPV): males and females ages 9 to 26 years

    • Measles, mumps, rubella (MMR): if seronegative (see Pediatric Candidates section)

    • Varicella—if seronegative

    • Note: Live vaccine: must avoid transplantation 4 weeks following administration

    • Bacille Calmette-Guérin (BCG)—unavoidable exposure to TB

  • Pediatric Candidates: same as adult candidates with the following exceptions:

    • Hepatitis A: all pediatric candidates.

    • N. meningitidis (MCV4): all candidates 11 to 18 years of age and as young as 9 months with special circumstances (see Adult Candidates section).

    • Varicella: vaccine should be administered after 12 months of age with second dose approximately 3 months later.

    • Measles, mumps, rubella (MMR) may be administered as early as 6 months of age and repeated after 4 weeks following the first injection.

    • Wait at least 4 weeks between administration of live vaccines and transplant procedure for all adult and pediatric candidates.


A. Key Points5

  • Donor-transmitted infection is frequently associated with significant recipient morbidity and mortality.6

  • Despite advances in surgical technique, immunosuppression, and infection prevention, unexpected transmission of infections from donor to recipient is an infrequent complication of transplantation.7

B. Donor Risk Assessment

  • Donor chart review

  • Discussion with available family, friends, and/or acquaintances for knowledge of

    • Prior infections

    • Immunizations

    • Unusual exposures to infection

    • Psychosocial history

      • Alcohol/drug abuse

      • Incarceration

      • High-risk sexual behavior/multiple sex partners

      • Tattoos

      • Body piercing

    • Socioeconomic status/challenges

      • Living conditions

      • Health care access

      • Medical adherence

      • Poverty

      • Language barriers

C. Physical Examination

  • Performed by organ procurement team and procuring surgeon

  • Evidence of active infections including abscesses, ulcers, genital/anal trauma, lymphadenopathy

  • Evidence of recent drug use such as track marks

  • Evidence of underlying disease (cirrhosis, skin lesions, or other malignancies)

  • Other abnormalities such as free spillage of intestinal contents or obvious pus or sign of infection involving specific donor organs and/or vessels

D. Laboratory Studies

  • Donor testing includes the following:

    • Complete blood cell count (CBC)

    • Microbial cultures (e.g., blood, urine)

    • Serologic assay (e.g., antibodies against HIV, hepatitis B virus [HBV]), and hepatitis C virus [HCV]) and, in certain cases, nucleic acid testing (NAT) (including assays for HIV, HCV, or HBV).7

  • Ideally, serologic testing should be performed before and after blood product administration.

  • If serologic testing is done after the donor is transfused, the number of blood product units should be recorded.

E. High-Risk Donors

  • Public Health Service (PHS) guidelines developed in 1994 provide guidance to minimize the risk of HIV transmission and to monitor recipients following the transplantation of “high-risk” organs.8

  • The intent of the PHS guideline is to improve organ transplant recipient outcomes by reducing the risk of unexpected HIV, HBV, and HCV transmission, while preserving the availability of high-quality organs using an evidence-based approach to formulate the recommendations.8

  • Transplant programs must obtain specific informed consent from the intended recipient according to the guidelines specified in the Organ Procurement and Transplant Network (OPTN) Policy 15.3 (Figure 5-1).8,9

  • Behavior/History Criteria established by the PHS as “high risk” for transmitting HIV or other infectious diseases despite negative preliminary testing:

    • People who have had sex with a person known or suspected to have HIV, HBV, or HCV infections in the preceding 12 months

      FIGURE 5-1 Organ Procurement and Transplantation Network Policy 15.3: informed consent of transmissible disease risk (available at:

    • Male with male (MSM) sex in the preceding 12 months

    • Women who have had sex with a man with a history of MSM behavior in the preceding 12 months.

    • People who have had sex in exchange for money or drugs in the preceding 12 months.

    • People who have had sex with a person who had sex in exchange for money or drugs in the preceding 12 months.

    • People who have had sex with a person who has injected drugs by IV, IM, or SQ route for nonmedical reasons in the preceding 12 months.

    • A child who is <18 months of age and born to a mother known to be infected with or at increased risk for HIV, HBV, or HCV infection.

    • A child who has been breast-fed within the preceding 12 months and the mother is known to be infected with or at increased risk for HIV infection.

    • People who have injected drugs by IV, IM, or SQ route for nonmedical reasons in the preceding 12 months.

    • People who have been in lockup, jail, prison, or a juvenile correction facility for more than 72 hours in the preceding 12 months.

    • People who have been newly diagnosed with or have been treated for syphilis, gonorrhea, Chlamydia, or genital ulcers for the preceding 12 months.

    • People who have been on hemodialysis in the preceding 13 months should be identified as high risk for HCV infection only.


A. Key Points

  • Early, specific diagnosis and rapid, aggressive treatment are essential in obtaining favorable outcomes when infection occurs posttransplantation.

  • Etiologies of infections are diverse and include common viral and bacterial diseases and uncommon opportunistic infections that are clinically significant only in immunocompromised hosts.

  • Immunosuppression impairs inflammatory responses normally associated with microbial invasion.

B. Exposure to Infection

  • Epidemiologic exposure

  • Latent pathogens can reactivate in the setting of immunosuppression

    • Cytomegalovirus (CMV), herpes simplex virus (HSV), varicella-zoster virus (VZV, shingles), HBV, HCV, papillomavirus, and BK polyomavirus frequently reactivate after transplantation.

    • Geographically restricted systemic mycoses (histoplasmosis, coccidioidomycosis, diseases caused by the parasite Trypanosoma cruzi) may have occurred many years pretransplantation.

    • Significance of exposure varies based upon specific immune deficit(s).

    • Bacterial (Staphylococcus spp., Streptococcus spp.) and fungal (Candida spp., Aspergillus spp.) pathogens are more significant in the setting of neutropenia.11

    • Viral (CMV) and intracellular (TB) infections are more common with T-cell immune deficits.

    • Strongyloides stercoralis may reactivate many years after exposure.

  • Community-acquired pathogens

    • Respiratory viruses such as influenza, respiratory syncytial virus (RSV), and adenovirus

    • Bacterial pathogens such as Streptococcus pneumoniae, Legionella, and Salmonella

  • Food-borne illnesses caused by organisms such as Escherichia coli, Cryptosporidium, Salmonella, Toxoplasma gondii (usually related to contact with cat feces), Vibrio vulnificus, and Campylobacter

  • Nosocomial infections

    • Prolonged hospitalization and mechanical ventilation increase vulnerability to hospital-acquired infections in the early postoperative period.

    • Gram-negative bacilli (Pseudomonas aeruginosa, Legionella)

    • Antimicrobial-resistant gram-positive organisms (vancomycin-resistant enterococci [VRE], methicillin-resistant Staphylococcus aureus [MRSA])

    • Fungi (Aspergillus spp. and nonalbicans or azole-resistant Candida species)

    • Clostridium difficile colitis12

    • See Table 5-2 for major pathogens that cause infectious disease in SOT recipients

C. Periods of Increased Risk

  • Early postoperative period when immunosuppression doses are highest

  • Increase in immunosuppressant therapy to treat acute rejection

D. Posttransplant Infection Timetable10,13

  • The posttransplant course can be divided into three time periods related to the risk of infection by specific pathogens (see Figure 5-2):

    • Early posttransplant period (days 0 to 30)

      • Infection from either donor or recipient

      • Infectious complications from surgery and/or hospitalization

    • Intermediate period (months 1 to 6)

      • Highest risk for developing opportunistic infections

      • Reflective of local epidemiology, immunosuppression, and antimicrobial prophylaxis

      TABLE 5-2 Major Pathogens that Cause Infection in Transplant Recipients





      Enteric gram-negative bacteria


      Candida species

      Toxoplasma gondii

      Pseudomonas aeruginosa

      Epstein-Barr virus

      Aspergillus species


      Legionella species

      Herpes simplex virus

      Cryptococcus neoformans

      Strongyloides stercoralis

      Nocardia asteroides

      Varicella zoster virus

      Pneumocystis carinii

      Listeria monocytogenes

      Hepatitis B virus

      Coccidioides immitis

      Salmonella species

      Hepatitis C virus

      Histoplasma capsulatum

      Mycobacterium tuberculosis

      Human herpesvirus 6

      Blastomyces dermatitidis

      Nontuberculous mycobacteria



      Respiratory syncytial virus

      Influenza virus



      From Green M. Introduction: infections in solid organ transplantation. Am J Transplant. 2013;13(suppl 4):3-8; Jani AA. Infections after solid organ transplantation. Medscape. 2014. Available at Accessed August 26, 2015; Fishman J. Infection in the solid organ transplant. In: Marr K, ed. Up to Date. Waltham, MA: Wolters Kluwer; 2015. Available at Accessed August 1, 2015.

      FIGURE 5-2 Infections in solid organ transplant recipients.CMV, cytomegalovirus; EBV, Epstein-Barr virus; HSV, herpes simplex virus; MRSA, methicillin-resistant Staphylococcus aureus; PML, progressive multifocal leukoencephalopathy; PTLD, posttransplant lymphoproliferative disorder; SARS, severe acute respiratory syndrome; VRE, vancomycin-resistant Enterococcus; VZV, varicella-zoster virus. (From Fishman JA; the AST Infectious Diseases Community of Practice. Introduction: infection in solid organ transplant recipients. Am J Transplant. 2009;9(suppl 4):S3. Copyright © 2009 American Society of Transplantation and the American Society of Transplant Surgeons. Reproduced with permission of John Wiley & Sons, Inc. Graphic 58770 Version 5.0.)

    • Late posttransplant period (>6 months)

      • Stable and reduced levels of immunosuppression for most patients.

      • Subject to community-acquired pneumonias and late viral infections.

      • Patients with suboptimal graft function require higher than normal levels of immunosuppression and are at highest risk for opportunistic infections (i.e., pneumocystis pneumonia [PCP], cryptococcosis, nocardiosis) and severe illness.

  • Significance of timetable

    • Common patterns of opportunistic infection are observed following solid organ transplantation based on epidemiologic exposures and the “net state of immunosuppression.”

    • The time line is altered based on the immunosuppressive regimen and prophylactic medications. The dynamic assessment of infectious risk represents assays that will measure an individual’s risk for infection due to specific pathogens or in general.

    • See Table 5-3 for posttransplant intervals for infection.10,14,15

  • Guide to develop antimicrobial strategies10,14,15

    • Develop differential diagnosis for the SOT recipient with clinical manifestations of infection.

    • Detect presence of excessive environmental risks (individual, community, nosocomial).

TABLE 5-3 Posttransplant Intervals of Infection

Time Period

Type of Infection


First month

Continuation of recipient’s pretransplant infection

Pseudomonas aeruginosa infections in lung transplant candidates with cystic fibrosis

Infections related to the surgical procedure, other iatrogenic procedures, and indwelling lines and catheters

Anastomotic leaks, obstructions lymphoceles Infection related to invasive lines, catheters1

Transmission of infection by the donor allograft

Staphylococcus, Streptococcus, Pseudomonas spp., Salmonella spp., Aspergillus spp., Candida spp. CMV, EBV, HHV-6, HSV, VZV, HTLV-1 and HTLV-2, HIV, HBV, HCV, LCMV, mycobacteria, West Nile virus, rabies, Chagas’ disease, Leishmania, toxoplasmosis, respiratory viruses

Early reactivation of latent viruses

Reactivation of herpes viruses

Months 2-6

Infections caused by opportunistic organisms or immunomodulating viruses

Reactivation of latent viral infections: CMV, EBV, HSV, VZV, HBV, HCV, BK polyomavirus

CMV, cytomegalovirus; EBV, Epstein-Barr virus; HHV-6, human herpesvirus 6; HSV, herpes simplex virus; VZV, varicella zoster virus; HTLV, human T-cell lymphotropic virus; HIV, human immunodeficiency virus; HBV, hepatitis B virus; HCV, hepatitis C virus; LCMV, lymphocytic choriomeningitis virus.

From Jani AA. Infections after solid organ transplantation. Medscape. 2014. Available at Accessed August 26, 2015; Morris MI, Fischer SA, Ison MG. Infections transmitted by transplantation. Infect Dis Clin North Am. 2010;24(2):497-514; Chong PP, Razonable RR. Diagnostic and management strategies for donor-derived infections. Infect Dis Clin North Am. 2013;27(2):253-270.

E. Other Factors Associated with Posttransplant Risks

  • Donor-derived infections6,7,14

    • Latent or unappreciated active infection in donor at time of transplant (CMV or Epstein-Barr virus [EBV] infection; toxoplasmosis)

    • Bloodstream infections (Staphylococcus, Pneumococcus, E. coli, Candida); adequate therapy should be confirmed prior to organ acceptance

  • Net state of immunosuppression: determined by interaction of several factors10

    • Immunosuppressive therapies

      • Type/dose of medications, plasmapheresis, IgG

    • Comorbidities such as

      • Diabetes

      • Malnutrition

    • Graft abnormalities

    • Concurrent neutropenia or lymphopenia

    • Invasive devices—vascular access devices, urinary catheters, drains

    • Concomitant infection with immunomodulating viruses

      • CMV

      • EBV

      • HHV-6

      • HBV

      • HCV

    • See Table 5-4 regarding factors that affect the diagnosis of posttransplant infection.1,10,15

TABLE 5-4 Factors to Consider in Diagnosis of Posttransplant Infection



Pretransplant host factors

Age, nutritional status, comorbidities (e.g., diabetes mellitus), medications (e.g., steroid use), infection history (particularly infections that further suppress the immune system, such as CMV, EBV, HBV, HCV)

Preoperative factors

Invasive devices (e.g., intra-aortic balloon pump, assist devices, mechanical ventilation, hemodialysis)

Type of organ transplanted

Risk of infection greater for lung transplant recipients

Perioperative factors

Ischemic time, blood loss, transfusions

Donor factors

Donor CMV seropositive, recipient CMV seronegative

Immunosuppression regimen

Maintenance therapy (medications, doses, frequency), use of antilymphocyte therapy, net state of immunosuppression

Rejection history

Severity, treatment, and response to treatment

Current antimicrobial regimen (if any)

Use of prophylactic antiviral, antifungal, and antibiotic therapy

Posttransplant exposure to nosocomial, community, or geographic sources of infection

Any recent hospitalizations, community outbreaks of infection, exposure to endemic bacteria, virus, and fungi

Onset of symptoms

Bacterial infections usually manifest over a 24-48 h time period, but they can evolve over several (3-5) days

From Green M. Introduction: Infections in solid organ transplantation. Am J Transplant. 2013;13(suppl 4):3-8; Jani AA. Infections after solid organ transplantation. Medscape. 2014. Available at Accessed August 26, 2015; Chong PP, Razonable RR. Diagnostic and management strategies for donor-derived infections. Infect Dis Clin North Am. 2013;27(2):253-270.


A. Key Points

  • Significant clinical manifestations of infection include the following10:

    • Usual signs of infection (e.g., fever, chills, generalized malaise) may be replaced by nonspecific symptoms (altered mental status, elevated liver function tests) due to immunosuppression

    • Fever without localizing findings or fever with headache

    • Central nervous system (CNS) changes, including changes in level of consciousness

    • Unexplained skin lesions

  • Important characteristics of CNS infections include the following5,7,10:

    • The signs of meningeal irritation may be masked by immunosuppression.

      • Changes in level of consciousness may be subtle.

      • The most reliable indication of a CNS infection is the simultaneous presence of unexplained fever and headache.

        • Patients presenting with these manifestations should have an immediate and complete neurologic workup (CT scan or magnetic resonance imaging [MRI] of brain; lumbar puncture [unless otherwise contraindicated]).


A. Key Points

  • The four classes of infection most prevalent after transplant include the following:

    • Bacterial

    • Viral

    • Fungal

    • Parasitic

  • Major infection causing pathogens

    • The major pathogens that cause infections in transplant recipients are listed in Table 5-2.1,10


A. Key Points

  • Leading a healthy and normal life is possible after transplantation.

  • The risk of exposure to infectious agents will always be present. Therefore, transplant recipients should be counseled on the modes of transmission and means to reduce the risk of infection.

    • Direct contact

      • Frequent and thorough hand washing is imperative and should take place

        • Before cooking and eating

        • Before and after touching wounds, even when using gloves

        • Before touching mucous membranes

        • After blowing nose or touching other secretions

        • After touching or cleaning up after pets or other animals

        • After gardening, touching soil or plants

        • After using the rest room or touching any items having contact with human or animal feces (toilets, bedpans, litter boxes)

    • Percutaneous exposures

      • Avoid intravenous and intradermal illicit drug use.

      • Tattoos and body piercings represent break in skin; all nonsterile practices should be avoided.

    • Pet safety and animal contact

      • Wash hands carefully after handling pets.

      • Avoid cleaning bird cages and feeders, litter boxes, and handling animal feces.

      • Avoid stray animals.

      • Avoid animal bites, scratches, and contact with animals having diarrhea.

      • Avoid contact with nonhuman primates (monkeys).

      • Wait approximately 6 to 12 months after transplantation before acquiring a new pet.

    • Safe sexual practices

      • Use latex condoms during periods of increased immunosuppression and/or outside of long-term monogamous relationships.

      • Avoid exposure to feces during sexual contact.

    • Inhalation

      • Avoid close contact with persons with respiratory illnesses.

      • Avoid crowded areas (elevators, subways, shopping malls) during periods of increased immunosuppression and epidemic illness circulation.

      • Avoid tobacco and marijuana smoke, which is associated with fungal spores.

      • TB exposure

        • Avoid individuals with known active disease.

        • Avoid persons with increased risk (i.e., those working in prisons, jails, homeless shelters).

      • Construction sites, excavations, and some home remodeling projects may have high concentration of dust with increased risk of mold exposure (Histoplasma, Aspergillus)

    • Ingestion

      • Water safety

        • Cryptosporidiosis may occur from drinking contaminated drinking water during recreational activities.

        • Using filters and/or drinking bottled water may reduce risk.

        • Abrasions acquired during swimming or bathing in contaminated water may pose risk to exposure to organisms such as Vibrio species, Mycobacterium marinum, or Aeromonas.

      • Food safety (items to avoid)

        • Unpasteurized milk, fruit, or vegetable juice (E. coli, Salmonella, Cryptosporidium)

        • Cheeses made with unpasteurized milk such as brie, feta (Listeria)

        • Raw or undercooked eggs (Salmonella)

        • Raw or undercooked meat, poultry, or fish (bacterial and parasitic infections such as tapeworms and Toxoplasma gondii)

        • Raw or undercooked seafood (Vibrio species, viruses that cause gastroenteritis or hepatitis, Cryptosporidium)

        • Cross-contamination of raw and cooked foods


A. Overview13,17

  • Epidemiology

    • Community exposure: influenza, adenovirus, parainfluenza, varicella

    • Allograft transmission: CMV, EBV, viral hepatitis, HSV

    • Reactivation of distant viruses: herpes simplex virus, BK virus, herpes zoster as shingles

  • Clinical

    • Direct effects: fever, neutropenia, and invasive disease (e.g., pneumonia, hepatitis, meningitis)

    • Indirect effects:

      • Alteration in the net state of immunosuppression and increased susceptibility to opportunistic infections

      • Potential allograft injury

      • Potential oncogenesis

B. Herpes viruses

  • Eight members of the herpes viruses family that can cause disease after SOT:

    • Herpes simplex virus 1 and 2

    • Varicella-zoster virus (VZV)

    • Epstein-Barr virus or HHV-4

    • Cytomegalovirus or HHV-5

    • HHV-6, HHV-7: roseola infantum18

      • Primary infection first 5 years of life and then latent.

      • In SOT, cases due to reactivation/reinfection and transient with few clinical symptoms. No antiviral therapy needed.

    • HHV-8

      • After SOT, endemic in certain regions (i.e., Saudi Arabia; South Africa) causing Kaposi’s sarcoma (KS), Castleman’s disease, and primary effusion lymphoma.

      • Treatment consists of reduction/withdrawal of immunosuppression, chemotherapy, and possible conversion to mammalian target of rapamycin (mTOR) inhibitors.

  • Can be transmitted directly but usually characterized by viral latency.

  • Replication of latent herpes viruses can be triggered by net immunosuppression in the SOT recipient.17

  • Herpes virus “infection” versus “disease”

    • The term “infection” refers to the presence of viral replication as indicated by cultures or serological testing (i.e., polymerase chain reaction [PCR] from cerebrospinal fluid, visceral tissue samples, and/or direct fluorescence antibody from vesicular lesions).

    • The term “disease” indicates that the patient has specific symptoms that are caused by a herpes virus. Viremia and/or tissue invasion are present. Tissue invasion can manifest as esophagitis, hepatitis, tracheobronchitis, and, often, disseminated disease.

C. Herpes simplex virus (HSV)13,17

  • Overview

    • Approximately 80% of adult transplant recipients are HSV seropositive.

    • Incidence highest in kidney transplant recipients.

    • Most common strains associated with mucocutaneous ulcerative infections: HSV-1 and HSV-2.

    • HSV-1 is more common with oral lesions, which may extend beyond the lip into the oral cavity and esophagus.

      • Herpes labialis is the most common clinical manifestation of HSV-1.

      • Lesions may bleed, interfere with nutritional intake, and require local analgesia to control pain.

    • HSV-2 involves the perianal and genital areas.

    • After a primary HSV infection, the virus remains latent in the sensory nerve ganglia.

    • Reactivation infection occurs in up to 40% of recipients, typically during the first posttransplant month.

  • See Table 5-5 for the clinical manifestations, prevention/prophylaxis, diagnosis, and treatment of HSV.

D. Varicella zoster virus (VZV)—Human herpesvirus 3 (HHV-3)13

  • Overview

    • VZV is a highly infectious alphaherpesvirus that is acquired through skin-to-skin contact or airborne respiratory droplets.

    • VZV causes chickenpox as a primary infection and then becomes latent in nerve root ganglia until possible reactivation later in life as shingles.

    • Most SOT recipients have developed VZV antibodies so that reactivation of the virus accounts for 90% of adult recipients.

      TABLE 5-5 Major Organisms Causing Posttransplant Infection: Clinical Manifestations, Prevention/Prophylaxis, Diagnostic Tests, and Treatment Options


      May Cause

      Clinical Manifestations

      Prophylaxis/Preemptive Therapy

      Diagnostic Tests

      Treatment Options


      CMV syndrome Tissue-invasive disease:

      CMV syndrome:

      CMV-negative, filtered, or leukocyte-poor blood products

      Prophylaxis: valganciclovir is first choice

      Oral ganciclovir

      IV ganciclovir

      Valacyclovir used for minimal risk recipients or if cost an issue

      Done for 3-12 mo posttransplant


      Weekly quantitative CMV-PCR assays for at least 3 mo posttransplant

      If positive, may treat

      Duration of prophylaxis: range: 3-12 mo posttransplant

      Serologic: helpful pretransplant but not diagnostic for infection

      Complement fixing assay

      Immunofluorescence ELISA

      Latex agglutination systems


      IV ganciclovir

      Oral ganciclovir

      CMV hyperimmune globulin for tissue-invasive disease


      For ganciclovir-resistant organisms:






      Retinitis (rare)

      Encephalitis (rare)

      Pancreatitis (rare)




      Elevated LFTs


      Antigenemia assay

      Quantitative PCR


      Ganciclovir + foscarnet

      Anorexia, dysphagia

      Abdominal cramping

      Nausea, vomiting, diarrhea

      Ulceration, bleeding

      Tissue culture


      Antigenemia: CMV pp65 detected in leukocytes CMV DNA detected in plasma, whole blood, isolated peripheral blood leukocytes, or buffy coat specimens RNAemia: CMV RNA detected in plasma, whole blood, isolated peripheral blood leukocytes

      Foscarnet+ Cidofovir

      Intravenous immune globulin (IVIG)




      Epstein-Barr virus10,17

      Mononucleosis PTLD: nodal or extranodal disease of CNS, GI tract, lungs, or bone marrow


      Preemptive therapy for patients at high risk (e.g., IV ganciclovir during antilymphocyte antibody therapy)



      Lymph node hyperplasia


      Atypical mononuclear leukocytes

      Abnormal LFTs


      EBV antibody


      Heterophil agglutination antibody test


      PTLD: benign polyclonal polymorphic B-cell hyperplasia:

      May consider acyclovir





      Sore throat

      CT scan: Note: absence of adenopathy does not rule out PTLD; disease can be entirely extranodal

      Tissue biopsy

      immunosuppression (possibly)


      PTLD: early malignant polyclonal polymorphic B-cell lymphoma:

      Mononucleosis-like syndrome

      Weight loss

      Fever of unknown origin

      Abdominal pain



      Bowel perforation

      GI bleeding

      Renal and hepatic dysfunction


      Pulmonary infiltrates

      CNS findings (seizures, altered LOC)

      Allograft involvement




      Gamma globulin

      Anti-B-cell antibodies (anti-CD20)

      Decreased immunosuppression (possibly)

      PTLD: monoclonal polymorphic B-cell lymphoma:




      Decreased immunosuppression

      Herpes simplex virus 117

      Herpes simplex virus 217

      Herpes labialis

      Herpetic esophagitis

      Anogenital lesions

      Visceral infection is rare


      Acyclovir (low-dose)

      Ganciclovir (has low oral bioavailability)



      Duration of prophylaxis: typically 30-90 d

      Viral culture

      Direct immunofluorescence studies

      Tzanck smear






      Foscarnet for resistant strains

      Crusted ulcerations


      Coalescing ulcerations without clear-cut vesicles

      Varicella zoster15,17,22

      Localized dermatomal zoster

      Disseminated infection

      Bone marrow suppression


      Interstitial pneumonitis

      Localized dermatomal zoster that involves two or three adjoining dermatomes without visceral involvement (viral reactivation)

      Primary, disseminated infection: associated with hemorrhagic pneumonia, skin lesions, encephalitis, pancreatitis, hepatitis, and disseminated intravascular coagulation

      Two noncontiguous dermatomal involvement




      Bone marrow dysfunction

      Seronegative recipients with significant exposure (same room contact with diagnosed case of chickenpox or direct contact with skin lesion of shingles)

      Varicella zoster hyperimmune globulin within 72 h of significant exposure

      IV acyclovir within 24 h of eruption of skin rash

      None at present

      Characteristic unilateral vesicular lesions

      VZV antibody titer

      Tzanck smear

      Direct immunofluorescence studies


      Serologic testing PCR assay

      Localized infection:

      Acyclovir (oral)

      Famciclovir (oral)

      Valacyclovir (oral)

      Disseminated infection:

      Acyclovir (IV; high-dose)


      VZV immune globulin for VZV-seronegative recipients within 72 h of exposure to VZV



      Hepatitis viruses17,23,24

      Acute or chronic hepatitis


      Recurrent HBV infection:

      HBV vaccine for nonimmune transplant candidates

      Perioperative anti-HBV immune globulin for liver transplant candidates with HBV infection


      HBV: Immune globulin

      + HbsAg (typically 2-6 mo posttransplant)

      Serologic testing

      Hepatocellular symptoms that can range from mild hepatitis to fulminant liver failure

      HCV: chronic hepatitis


      Detection of HCV-RNA by reverse transcriptase PCR

      Liver biopsy

      Polyomavirus: BK virus15,25,26

      Tubulointerstitial nephritis

      Ureteral stenosis

      Obstructive nephropathy

      Progressive graft dysfunction

      Graft loss


      Persistent hematuria

      Elevated serum creatinine level

      Plasma and urine assays: detection of virus DNA by PCR

      Urine cytology: detection of characteristic “decoy” cells


      Tissue biopsy (gold standard) May be difficult to differentiate virus infection from rejection; definitive diagnosis requires visualization of polyomavirus inclusion bodies in biopsy specimen

      Decrease immunosuppression agents under investigation



      Quinolone antibiotics


      Supportive care

      Polyomavirus: JC virus15,25,26

      Multifocal demyelination in brain

      Progressive demyelinating

      PML progressive multifocal leukoencephalopathy

      Progressive neurologic deficits

      May involve cerebral cortex, brain stem, or cerebellum

      Cortical syndromes:

      MRI of head

      CT scan


      PCR analysis of spinal blood and spinal fluid

      Biopsy of brain with in situ hybridization for JC virus

      Cessation of immunosuppression

      Corticosteroid therapy

      Nucleoside analogs: interfere with DNA synthesis:

      Visual deficits (hemianopsia)


      Frontal lobe dementia

      Cytosine arabinoside

      Adenosine arabinoside


      Brain stem lesions:


      Contralateral hemiparesis or hemisensory deficits

      Interferons: stimulate natural killer cells

      Unilateral lesions:

      Nucleoside analogs: interfere with DNA synthesis:


      Limb incoordination

      Cytosine arabinoside

      Adenosine arabinoside

      Midline lesions:



      Imbalance, falls


      Gait disturbance

      Cerebellar lesions:

      Blurred vision


      Classic triad: dementia, hemiparesis, hemianopsia

      Respiratory syncytial virus27,28

      Upper respiratory infection

      Lower respiratory tract disease

      Organ rejection

      Bronchiolitis obliterans


      Sinus congestion


      Nausea; abdominal pain



      Fever >100.4°F (38°C)

      Wheezing, rales, rhonchi

      Infiltrates on chest


      Sinusitis on sinus radiograph

      Aggressive infection control measures

      Aerosolized ribavirin


      Antigen detection by immunofluorescence assay

      Antigen detection by immunoassay

      RNA detection by reverse transcription PCR


      Demonstration of RSV-IgM antibody (acute infection)

      Significant ↑ in RSV-IgG antibody between acute- and convalescent-stage sera

      Culture: less sensitive and specific in adult vs. pediatric population

      Aerosolized ribavirin


      RSV pneumonitis:

      Aerosolized ribavirin

      Palivizumab (RSV monoclonal antibody) plus aerosolized ribavirin

      Influenza virus27,28

      Influenza syndrome

      Secondary bacterial complications




      Cough (typically nonproductive)

      Sore throat




      Aggressive infection control measures

      Annual vaccination of patients and household contacts (unless otherwise contraindicated)

      Annual vaccination of health care workers

      History and clinical examination

      Detection of virus-infected cells (via nasopharyngeal washing or respiratory secretions) with specific fluorescent-labeled antibody probes

      Influenza A: early administration of:



      Influenza B:



      If started within 36-48 h of symptom onset

      Parainfluenza virus27,28

      Can cause mild upper respiratory disease

      May progress to pneumonia

      May mimic influenza

      No definitive recommendations

      Viral isolation

      Viral shell assays

      Rapid antigen detection

      Ribavirin has been used for lower respiratory tract disease


      Asymptomatic or mild respiratory illness that may progress to fatal respiratory failure (SARS)

      Fever >100.4°F (38°C)





      Shortness of breath





      Mild ↑ in transaminases

      No definitive recommendations

      Chest radiograph (evidence of pneumonia or adult respiratory distress syndrome)

      Detection of viral RNA by real-time reverse transcription-PCR

      Detection of acute and convalescent antibodies to SARS by enzyme immunoassay

      Supportive care

      Empiric antimicrobial agents

      Intravenous administration of ribavirin



      Parvovirus B1910,15

      Severe, refractory anemia


      Thrombotic microangiopathy

      Fibrosing cholestatic hepatitis

      Graft dysfunction

      Chronic anemia

      ↓ platelets

      ↓ white blood cell count




      No definitive recommendations

      Detection of parvovirus B19 DNA in serum by PCR assay

      High-dose IVIG

      ↓ in immunosuppression

      Discontinuing tacrolimus (if possible)

      Human papillomavirus10,15

      Cutaneous warts

      Anogenital warts

      Carcinoma of cervix and bladder

      Squamous cell carcinoma

      Anogenital carcinoma


      Avoidance of excessive sun exposure and ultraviolet light

      Sun precautions

      Sunscreen with high sun protection factor (≥15)

      Tissue biopsy

      Topical keratolytic agents

      Caustic agents

      Topical retinoids

      Oral retinoids

      Podophyllin, 5-fluorouracil



      Carcinoma (skin, cervix, urinary tract):




      Squamous cell carcinoma that arises in beds of flat warts


      Reduction or withdrawal of immunosuppression

      Radiation chemotherapy

      Listeria monocytogene10,22





      Cerebritis without meningitis

      Less common manifestations:

      Fever (1-5 d)


      Decreased LOC

      Focal neurological deficits


      Nuchal rigidity

      Spinal fluid: neutrophils, lymphocytes; glucose may be normal

      Abdominal cramps, diarrhea



      Dietary precautions regarding milk, cheeses, undercooked meats, and uncooked vegetables

      Blood, sputum cultures

      CT scan


      CSF cell count, Gram stain, culture, and protein and sugar determination

      Note: organism may be confused with diphtheroids in Gram stain smears of pus or sputum

      Diagnosis confirmed by isolation of Listeria monocytogenes from culture of blood, CSF, or other sterile source

      Treatment of choice: ampicillin + aminoglycoside

      Meningeal doses of penicillin or ampicillin


      TMP-SMZ for penicillin-allergic patients









      Pulmonary and extrapulmonary infection (CNS, skin, and bone)

      Subacute onset is typical

      Subacute symptoms:


      Typical pneumocystis pneumonia prophylaxis with TMP-SMZ offers some protection

      Cultures: sputum, BAL fluid

      Gram stain

      Modified acid-fast stain

      Diagnosis confirmed by the presence of Nocardia species in culture

      Sulfonamides preferred





      Third-generation cephalosporins



      Isolated pulmonary infection: 3-6 mo of therapy

      Disseminated disease: 12 mo of therapy



      Chest pain

      Pulmonary nodules, abscesses, cavitating lesions, infiltrates, effusions



      Fever, chills

      Focal pulmonary infiltrate



      Minimally productive cough


      Chest pain



      Routine culture of hospital water supply

      Water treatment to control nosocomial infection

      Cultures: sputum, BAL fluid

      Direct fluorescent antibody stain of respiratory secretions

      Urinary antigen detection: can only detect serogroup 1 of Legionella pneumophila species

      Fine needle aspiration of lung

      Open lung biopsy

      Chest radiograph: dense infiltrates (unilateral or bilateral) that may → cavitation

      Diagnosis confirmed by: Legionella antigen in urine

      Direct fluorescent antibody stain (respiratory secretions or tissue biopsy)

      Culture of lower respiratory tract secretions

      Quinolones (particularly levofloxacin or ciprofloxacin)

      Rifampin (may interact with other drugs via the hepatic cytochrome p450 system)

      Macrolides (azithromycin, erythromycin) interact with immunosuppressive medications and should generally be avoided)

      TMP-SMZ (but the side effects include bone marrow suppression, hepatitis, rash)


      Pulmonary infection

      Extrapulmonary infection (intestinal, skeletal, bone, genitourinary, cutaneous, CNS)

      Disseminated disease3


      Nonproductive cough

      Mucopurulent secretions



      Chest pain


      Excessive sweating

      Weight loss

      Organ-specific manifestations

      Test and treat before transplantation

      Isoniazid (controversial)

      Tuberculin test: positive in 25%-33% of recipients infected with this disease

      Chest radiograph

      Bronchoscopy with BAL

      Transbronchial biopsy

      Pleural needle biopsy

      Tuberculin test: often negative

      Smears for acid-fast bacilli and mycobacterial culture

      Organ-specific histology

      Isolates require antimicrobial susceptibility testing

      Isoniazid (hepatotoxic)

      Rifampin (hepatotoxic)


      Ethambutol (may → optic neuritis)

      Streptomycin (ototoxic; nephrotoxic)

      Increases catabolism of steroids and cyclosporine and tacrolimus; monitor levels of cyclosporine and tacrolimus; monitor patient for rejection

      Monitor renal and hepatic function

      Recipients with active disease: 9-12 mo of therapy with two agents to which pathogen is susceptible


      Pulmonary and extrapulmonary infection

      Disseminates to:

      Depend on site(s) involved

      Pulmonary involvement:

      No definitive recommendations

      Heart, lung, heart-lung recipients: aerosolized amphotericin B

      Lung recipients: oral itraconazole for patients with airway colonization

      Epidemiologic: minimize contact with fungal spores; shield patient from nosocomial environmental hazards: high-efficiency particulate air filters; high-performance masks

      Preemptive: amphotericin B if respiratory tract is colonized

      Chest radiography

      Amphotericin B

      Itraconazole (oral or IV)

      Voriconazole: recently shown to have greater efficacy than amphotericin B for invasive disease

      Use of voriconazole with sirolimus is contraindicated

      Caspofungin: approved for refractory aspergillosis

      Absorption may be erratic, especially in patients with low gastric acidity; monitor plasma concentration of drug

      Note: may be normal

      Nonproductive cough

      Pleuritic chest pain


      Transbronchial biopsy






      Blood vessels



      GI tract

      Pulmonary infiltrates or nodules


      Low-grade fever

      Open lung biopsy

      CT scan (e.g., lung, sinuses)

      Tissue biopsy

      CT or MRI for brain abscesses

      Sputum cultures

      Repeated positive cultures suggest invasive disease

      Positive sputum cultures plus cavitary lung disease suggest invasive disease

      Invasive/disseminated infection:

      Refractory fever


      Epistaxis; nasal pain

      Periorbital pain or swelling

      Cutaneous embolic lesions

      Progressive erythema or induration along tunneled venous catheter

      Focal neurologic findings

      May → nephrotoxicity in patients on calcineurin inhibitors; monitor renal function (lipid formulations are less likely to be nephrotoxic; may be preferable for chronic treatment)

      Associated with higher relapse rates than amphotericin B

      Hemoptysis: sign of invasive disease


      Mucocutaneous candidiasis

      Oropharyngeal thrush

      Candidal esophagitis





      Sternal wound infection; mediastinitis

      Intra-abdominal abscesses



      Disseminated infection


      Clotrimazole troches

      Oral Nystatin

      Liver transplant recipients:

      Direct fluorescent antibody stain of respiratory secretions

      Localized infection:

      Amphotericin B and lipid-based preparations

      Lipid-based preparations: less nephrotoxic



      Fluconazole for esophagitis and refractory candidiasis

      Candidemia in unstable or critically ill patients: Amphotericin B followed by fluconazole if organism is sensitive to fluconazole

      Candidemia in stable patients: Fluconazole, if organism is sensitive to fluconazole

      Candida albicans:

      White patches or ulcers in mouth


      Preoperative oral bowel decontamination with nystatin to ↓ gut colonization

      Cultures with Gram stain

      White or yellow vaginal discharge


      Disseminated candidiasis:

      Blood cultures

      CT scan


      Kidney and pancreas-kidney transplant recipients:

      Biopsy of skin lesions

      Tissue biopsy

      Erythematous, popular skin rash


      Preemptive therapy for asymptomatic candiduria

      Diagnosis confirmed by isolating Candida species from culture specimens

      Redness, swelling, suppuration around nail edge

      Pancreas transplant recipients:


      Anecdotal reports of fluconazole prophylaxis for high-risk patients:

      Thickened, discolored nails

      Intravascular catheter infections

      Fever, sepsis

      Enteric drainage



      Pretransplant peritoneal dialysis

      Candida krusei:

      Typically resistant to fluconazole

      Pancreas after kidney transplant

      Reperfusion pancreatitis


      Requires maximal doses of amphotericin B

      Newer agents: for Candida species



      Monitor renal function and cyclosporine levels; adjust dose accordingly

      Effective for most Candida species except Candida krusei and Candida glabrata

      When used with cyclosporine, may ↑ risk of hepatotoxicity; monitor liver function

      When used with tacrolimus, may → ↓ tacrolimus levels; monitor tacrolimus levels

      Cryptococcus neoformans31,35

      Predilection for CNS


      Brain abscesses

      Secondary seeding of skin, CNS, eye, urinary tract, and skeletal system

      Pulmonary infection

      Pulmonary infection: cough

      Primary prophylaxis: not recommended

      Lumbar puncture

      CT scan


      Blood culture

      CSF analysis: cell count; protein and sugar; Gram stain; acid-fast and fungal stains and cultures (fungal, bacterial, and mycobacterial)

      Cryptococcal antigen test on blood, CSF, and pleural fluid

      CSF in meningitis:

      Lymphocytic pleocytosis

      ↑ protein

      ↓ sugar

      ↑ opening pressure

      Definitive diagnosis: detection of antigen in serum and CSF

      Amphotericin B

      Amphotericin B with 5-flucytosine

      Fluconazole with 5-flucytosine


      Course of treatment: minimum of 8-10 wk

      Requires monitoring of renal function and cyclosporine levels

      Requires monitoring of 5-flucytosine levels to minimize hepatic and bone marrow toxicity

      Lung nodules

      CNS involvement:

      Progressive headache

      Memory or attention deficits

      Emotional disturbance

      Disorders of balance

      Cranial nerve dysfunction





      Muscle weakness, tremor

      Urinary incontinence

      Focal neurologic signs


      Subacute presentation:

      Low-grade fever


      Altered mental status

      Cutaneous involvement:


      Papules or pustules

      Subcutaneous swelling or tumors





      Palpable purpura or papules

      Necrotizing vasculitis


      Pneumocystis carinii36,37


      Presentation typically subacute


      Nonproductive cough




      Diffuse pulmonary infiltrates

      TMP-SMZ (low dose for 6 mo)


      Aerosolized pentamidine


      In patients with G6PD deficiency, evaluate risk of dose-dependent hemolytic anemia

      Transbronchial lung biopsy

      Needle biopsy of lung

      Bronchoalveolar lavage

      Chest radiograph (may be negative)

      Confirmatory diagnosis: direct staining of specimens: sputum, BAL lavage or lung tissue

      TMP-SMZ (high-dose) for 21 d



      Clindamycin-primaquine (if not G6PD deficient)

      Dose may have to be adjusted for renal dysfunction

      Histoplasma capsulatum38

      Disseminated infection (most common presentation)

      Subacute respiratory illness with either focal or disseminated interstitial or miliary infiltrates

      Fever (not always present)

      Night sweats




      Arthritis, myalgias

      CNS manifestations


      Cutaneous, intestinal, oral mucosal lesions

      No firm recommendations; some centers use itraconazole for seropositive recipients

      Methenamine-silver stain

      Peripheral blood stains

      Cultures: blood, respiratory secretions, tissue


      Antigen detection (urine, serum, CSF, BAL fluid)

      Chest radiography (may be normal)

      Amphotericin B

      Itraconazole for maintenance therapy

      Requires monitoring of renal function and cyclosporine levels

      Absorption may be erratic, especially in patients with low gastric acidity; monitor plasma concentration of drug

      Toxoplasma gondii39







      Mononucleosis-like syndrome of fever, malaise, and lymphadenopathy

      Myocardial dysfunction that mimics rejection

      Pulmonary: fever, dyspnea, cough, hemoptysis

      CNS involvement: multiple focal neurologic deficits, altered mental status; fever with headache

      Particularly for seronegative recipient/seropositive donor:

      Pyrimethamine (for sulfa allergy)

      Pyrimethamine + sulfonamide

      Pyrimethamine + folinic acid




      Avoid changing cat litter boxes

      Avoid raw or undercooked meat

      Endomyocardial biopsy

      Antibody titers

      Lung lavage and/or biopsy

      CT scan of head

      Chest radiograph

      Tissue and/or blood culture

      Serologic assays

      Definitive diagnosis: histological detection of trophozoites + inflammation

      Pyrimethamine with folinic acid and sulfadiazine

      Sulfa allergy: dapsone used instead of sulfadiazine

      Clindamycin and pyrimethamine with folinic acid

      Folinic acid given to prevent myelotoxicity

      Continue therapy for 2-3 wk after acute infection has resolved



      Gallbladder infection

      Profuse, watery diarrhea

      Abdominal pain

      Nausea and vomiting



      Boil water for 5 min or use distilled or filtered water

      Avoid ice cubes in restaurants

      Avoid soda fountain drinks

      Stool testing

      Antibody detection assays

      Small or large bowel biopsy

      Replace fluid and electrolytes

      Maintain nutritional status

      Spiramycin effective for some patients; adverse effects reported (increased stool output and volume loss)

      Strongyloides stercoralis41

      Ulcerating hemorrhagic enterocolitis

      Hemorrhagic pneumonia

      Disseminated disease:


      CNS (gram-negative meningitis)


      Consider preemptive ivermectin for transplant candidates who have traveled to or lived in endemic areas

      Screen at-risk candidates for infection

      Treat established infection before transplantation

      Stool specimen for rhabditiform larvae (may be negative)

      Papanicolaou stain of duodenal aspirates, urine, ascitic fluid, sputum, and stool

      Jejunal biopsy

      Serologic testing

      Chest radiograph (frequently inconclusive)

      Definitive diagnosis: presence of larvae in stool




      Taper immunosuppressive agents

      Systemic antibacterial therapy for bacteremia or meningitis

      Periodic retreatments may be necessary

      Hyperinfection: 7-10 d of antimicrobial therapy

      Abdominal pain and distention


      Nausea and vomiting

      Adynamic ileus

      Small bowel obstruction







      Hemoptysis CNS:



      Eosinophilic meningitis

      Mental status changes


      Focal neurologic deficits

      Gram-negative meningitis

      Skin manifestations:

      Migratory, raised, linear rash that may move at a rate of 10 cm/hr

      Crops of urticarial eruptions; immediate hypersensitive reactions to migrating worms, especially on the waist and buttocks)

      BAL, bronchoalveolar lavage; CT, computed tomography; CMV, cytomegalovirus; CSF, cerebrospinal fluid; CBC, complete blood count; CNS, central nervous system; EBV, Epstein-Barr virus; ELISA, enzyme-linked immunosorbent assay; EEG, electroencephalogram; G6PD, glucose-6-phosphate dehydrogenase; GI, gastrointestinal; LFT, liver function tests; HBV, hepatitis B virus; HbsAg, hepatitis B surface antigen; HCV, hepatitis C virus; HCV-RNA, hepatitis C virus ribonucleic acid; HHV, human herpesvirus 6; HSV, herpes simplex virus; IV, intravenous; IVIG, intravenous immunoglobulin; LOC, level of consciousness; MRI, magnetic resonance imaging; PCR, polymerase chain reaction; PTLD, posttransplant lymphoproliferative disease; SARS, severe acute respiratory syndrome; TMP-SMZ, trimethoprim-sulfamethoxazole; VZV, varicella zoster virus; UTI, urinary tract infection.

      Only gold members can continue reading. Log In or Register to continue

Oct 27, 2018 | Posted by in NURSING | Comments Off on Transplant Complications: Infectious Diseases
Premium Wordpress Themes by UFO Themes