Invasive pulmonary aspergillosis in solid organ and bone marrow transplant recipients.
BACKGROUND
Invasive pulmonary aspergillosis (IPA) remains a major cause of mortality in transplant recipients. New strategies in therapy are needed.


METHODS
We prospectively followed all solid organ and bone marrow transplant recipients from January 1998 to January 2003 who showed pulmonary infiltrates. We retrospectively analyzed all of the patients diagnosed as having IPA. Clinical and epidemiological data were collected. Influence of new treatment strategies on survival was also analyzed.


RESULTS
Thirty-one cases of API were found: 8 definite, 18 probable, 5 possible among recipients of liver (11), bone marrow (9), kidney (7), kidney-pancreas (3), and heart (1) transplants. Five patients (16%) were previously receiving antifungal prophylaxis. The most common symptoms were fever (74%) and dyspnea and dry cough (48%). Six cases (19%) showed dissemination to extrapulmonary sites: central nervous system (CNS) in five and bone in one. The most common radiographic patterns were alveolar infiltrates (58%); the lesions were usually diffuse and bilateral (58%). The most common Aspergillus species identified was A. fumigatus (74%). The test to detect Aspergillus antigen (galactomannan) in serum performed in 13 cases, was positive in eight (61%). The crude mortality rate was 61% (19 of 31), but in patients on mechanical ventilation, it was 94% (OR 88, IC 95%: 7.1-1094), and in patients with CNS involvement, it was 100%. The influence of the different treatment regimens on survival was analyzed in definite and probable cases: Group 1 (12) included patients who received conventional monotherapy and group 2 (12) patients received combination antifungal therapy or liposomal amphotericin B (1-AMB) at high doses. The mortality in group 1 was 83% (10 of 12), and in group 2 it was 42% (5 of 12) (P < 0.05).


CONCLUSIONS
The mortality rate of IPA remains high, especially among patients with CNS involvement or those under mechanical ventilation. Combined antifungal therapy or monotherapy with 1-AMB at high doses significantly reduced mortality compared with conventional monotherapy.
Trullas
J C
JC
Infectious Diseases Services, Hospital Clinic, IDIBPAS, Universitat de Barcelona, Spain. 34944jtv@comb.es
Cervera
C
C
Benito
N
N
de la Bellacasa
J Puig
JP
Agustí
C
C
Rovira
M
M
Mas
A
A
Navasa
M
M
Cofan
F
F
Ricart
M J
MJ
Pérez-Villa
F
F
Moreno
A
A
D000666:Amphotericin B / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use; D001229:Aspergillosis, Allergic Bronchopulmonary / Q000188:drug therapy / Q000453:epidemiology / Q000401:mortality / Q000473:pathology*; D016026:Bone Marrow Transplantation / Q000009:adverse effects*; D004359:Drug Therapy, Combination; D006801:Humans; D011183:Postoperative Complications / Q000188:drug therapy / Q000382:microbiology* / Q000401:mortality / Q000473:pathology; D012189:Retrospective Studies; D016019:Survival Analysis; D014181:Transplantation Immunology
D000935:Antifungal Agents; D000666:Amphotericin B