Antigenic differences between the EG95‐related proteins from Echinococcus granulosus G1 and G6 genotypes: implications for vaccination

Cystic echinococcosis caused by Echinococcus granulosus remains an important and neglected issue in public health. The study of the likely efficacy of the currently available EG95 vaccine against other genotypes of the parasite is important to improve the vaccine as a potential tool to be used in control programmes. The recombinant vaccine EG95‐1G1 was developed based on the G1 genotype of E. granulosus. Characterization of the eg95 gene family in the G6 genotype by genomic DNA cloning previously produced the first unequivocal information about the composition of the gene family in a different genotype. The information was used in this study to predict and express two EG95‐related proteins from the G6 genotype as recombinants, for assessment of their capacity to bind antibodies raised in sheep vaccinated with the EG95‐1G1 vaccine. The proteins (EG95‐1G6 and EG95‐5G6) from the G6 genotype of E. granulosus were unable to bind all the antibodies raised by sheep vaccinated with EG95‐1G1. Differences in the amino acid sequence of EG95‐related proteins from G6 and likely the differences in the encoded FnIII domain may be responsible for changes in the conformation of these epitopes.     

Community‐acquired carbapenem‐resistant Acinetobacter baumannii urinary tract infection just after marriage in a renal transplant recipient

Y. Solak, H. Atalay, K. Turkmen, Z. Biyik, N. Genc, M. Yeksan. Community‐acquired carbapenem‐resistant Acinetobacter baumannii urinary tract infection just after marriage in a renal transplant recipient.
Transpl Infect Dis 2011: 13: 638–640. All rights reserved Abstract: Urinary tract infection (UTI) is common in renal transplant recipients and may worsen allograft and patient survival. Many risk factors such as age, female gender, immunosuppression, comorbidity, deceased‐donor kidney transplantation, and uretheral catheterization are involved in development of UTI. Acinetobacter baumannii has rarely been reported as a causative agent for development of UTI. Here, we present an unusual case of a renal transplant recipient who developed community‐acquired carbapenem‐resistent A. baumannii UTI.     

Successful treatment of Ureaplasma‐induced hyperammonemia syndrome post‐lung transplant

Hyperammonemia, in the absence of significant liver dysfunction, is an uncommon but often fatal occurrence following orthotopic lung transplant. Prior reports have provided evidence to support Ureaplasma species as an etiology for this syndrome. This case report describes an individual post‐lung transplant, treated emperically with doxycycline along with other measures to lower ammonia levels, at the time hyperammonemia with encephalopathy was recognized. The patient clinically improved. Ureaplasma species were subsequently identified using 16S ribosomal RNA gene PCR/sequencing of pleural fluid, and by culture of bronchoalveolar (BAL) fluid. This case provides further support for empiric treatment of Ureaplasma species upon recognition of hyperammonemia syndrome post‐lung transplant.     

Non‐toxigenic Vibrio cholerae in an autologous stem cell and renal transplant recipient

A patient with a renal transplant after an autologous stem cell transplant for multiple myeloma developed non‐toxigenic Vibrio cholerae diarrhea after travel to Mexico. This is a rare cause of diarrhea in transplant recipients, and the patient had not had pre‐travel counseling. This case reflects the lack of referral of transplant recipients for travel infectious disease review before overseas travel and the role of the live attenuated cholera vaccine.     

Disseminated Acanthamoeba infection in a heart transplant recipient treated successfully with a miltefosine‐containing regimen: Case report and review of the literature

Disseminated acanthamoebiasis is a rare, often fatal, infection most commonly affecting immunocompromised patients. We report a case involving sinuses, skin, and bone in a 60‐year‐old woman 5 months after heart transplantation. She improved with a combination of flucytosine, fluconazole, miltefosine, and decreased immunosuppression. To our knowledge, this is the first case of successfully treated disseminated acanthamoebiasis in a heart transplant recipient and only the second successful use of miltefosine for this infection among solid organ transplant recipients. Acanthamoeba infection should be considered in transplant recipients with evidence of skin, central nervous system, and sinus infections that are unresponsive to antibiotics. Miltefosine may represent an effective component of a multidrug therapeutic regimen for the treatment of this amoebic infection.     

Hyperammonemia syndrome due to Ureaplasma infection after liver‐kidney transplant

Hyperammonemia syndrome, with high levels of ammonia and neurologic dysfunction, is a syndrome with historically high mortality that may occur after solid organ transplantation. Recently, this has been associated with infection due to Ureaplasma, mostly following lung transplantation. We describe the first case of hyperammonemia syndrome due to Ureaplasma infection after liver‐kidney transplantation. Our patient rapidly recovered after specific antibiotic treatment. It is important to consider these infections in the differential diagnosis for encephalopathy post‐transplant, as these organisms often do not grow using routine culture methods and polymerase chain reaction testing is typically required for their detection. This is particularly critical after liver transplantation, where a number of other etiologies may be considered as a cause of hyperammonemia syndrome.     

Unusual presentation of Q fever in a kidney‐pancreas transplant recipient

Q fever is uncommon in solid organ transplant (SOT) recipients. We describe a case of granulomatous lung disease as an unusual presentation of chronic Q fever in a kidney‐pancreas transplant recipient.     

Legionnaires' disease in transplant recipients: A 15‐year retrospective study in a tertiary referral center

Legionnaires' disease (LD) can be fatal among high‐risk transplant recipients. To understand the epidemiology of LD, we reviewed 15‐year longitudinal data from a center in Seattle, Washington that cares for both solid organ transplant (SOT) and hematopoietic cell transplant (HCT) recipients. We identified all laboratory‐confirmed LD and extracted data on species, diagnostic modalities, clinical presentation, management, and outcomes from medical records. Among 32 patients with LD, transplant recipients made up the majority of diagnoses (22, 69%; SOT 10, HCT 12). Approximately 0.8% of transplant recipients who underwent Legionella‐specific testing were positive. Non‐pneumophila Legionella species (LNLP), which are not detected by urinary antigen test, accounted for half the cases, led by Legionella micdadei (32%). The severity and outcome between Legionella pneumophila and LNLP infections were similar (attributed mortality, 36% vs 27%); all LNLP deaths occurred in transplant recipients with L. micdadei. The clinical and radiological features mimicked other opportunistic pathogens; 32% (n=7) were not on empiric treatment at the time of diagnosis. These data add to the emerging literature describing the importance of LD and highlight the need for both routine Legionella testing on transplant recipients with pulmonary findings and empiric Legionella‐active antibiotic therapy.     

Fulminant Epstein–Barr virus‐associated hemophagocytic syndrome in a renal transplant patient and review of the literature

We describe a rare fulminant case of Epstein–Barr virus‐associated hemophagocytic syndrome (HPS) in a 37‐year‐old female renal transplant patient, indistinguishable from severe sepsis clinically and in the laboratory. HPS involves rapidly escalating immune system activation, resulting in a cytokine cascade, which can, especially in immunocompromised patients, lead to multi‐organ failure, and even death. Thirty‐two Herpesviridae‐associated HPS cases in renal transplant patients have been reported and are reviewed. Overall mortality is 47% (15/32 cases).     

Donor‐derived strongyloidiasis after organ transplantation in Norway

Strongyloides stercoralis is an intestinal helminth which in humans can cause asymptomatic chronic infection maintained for decades through its auto‐infective cycle. During solid organ transplantation, recipients may unintentionally receive an organ infected with strongyloides. This is a very rare complication but may have deadly outcome if not detected. We hereby report two transplant recipients whom developed Strongyloides hyperinfection syndrome after organ transplantation from the same deceased donor. Recipient 1 was kidney transplanted and presented at day 65 post engraftment with diarrhea and subsequent septicemia and gastric retention. Larvae were detected in gastric aspirate. Recipient 2 was simultaneously kidney and pancreas transplanted and presented at day 90 post engraftment also with gastric retention and septicemia. Larvae were demonstrated on duodenal biopsy and stool sample. The clinical course was complicated with severe duodenal bleedings, gastric retention, meningitis, and prolonged hospitalization. Retrospective testing of pre‐transplant donor serum was positive for Strongyloides stercoralis antibodies. As a result of disease severity and gastric retention albenazole was administered via a jejunal tube and ivermectin subcutaneously in both recipients. S stercoralis was successfully eradicated and the transplants ended up with unaffected graft function. Following these two cases, we started systematic screening of all deceased donors for serum Strongyloides IgG in October 2016. After having screened 150 utilized donors one tested positive for Strongyloides, which initiated prophylactic ivermectin treatment to organ recipients. No symptoms or disease developed. Our center will continue to screen all donors as prophylactic treatment may avert this potentially lethal complication in cases of donor‐derived Strongyloides infection.     

Very early‐onset of Cryptococcus neoformans disease following liver transplantation: Report of two cases and a review of the literature

Cryptococcosis is the third most common invasive fungal infection following solid organ transplantation, and mortality is high. Most cases occur late and are due to reactivation of latent infection; however, very early reactivation and donor‐derived transmission can occur. Routine screening pre‐transplant and antifungal prophylaxis for cryptococcosis post‐transplant in solid organ transplantation are not standard practice. We present two cases of very early‐onset Cryptococcus neoformans disease following liver transplantation to highlight the need to consider individualized pre‐transplant screening and be aware that reactivation of Cryptococcosis neoformans can occur in the immediate post‐transplant period.     

RB but not R‐HCVAD is a feasible induction regimen prior to auto‐HCT in frontline MCL: results of SWOG Study S1106

Aggressive induction chemotherapy followed by autologous haematopoietic stem cell transplant (auto‐HCT ) is effective for younger patients with mantle cell lymphoma (MCL ). However, the optimal induction regimen is widely debated. The Southwestern Oncology Group S1106 trial was designed to assess rituximab plus hyperCVAD /MTX /ARAC (hyperfractionated cyclophosphamide, vincristine, doxorubicin and dexamethasone, alternating with high dose cytarabine and methotrexate) (RH ) versus rituximab plus bendamustine (RB ) in a randomized phase II trial to select a pre‐transplant induction regimen for future development. Patients had previously untreated stage III , IV , or bulky stage II MCL and received either 4 cycles of RH or 6 cycles of RB , followed by auto‐HCT . Fifty‐three of a planned 160 patients were accrued; an unacceptably high mobilization failure rate (29%) on the RH arm prompted premature study closure. The estimated 2‐year progression‐free survival (PFS ) was 81% vs. 82% and overall survival (OS ) was 87% vs. 88% for RB and RH , respectively. RH is not an ideal platform for future multi‐centre transplant trials in MCL . RB achieved a 2‐year PFS of 81% and a 78% MRD negative rate. Premature closure of the study limited the sample size and the precision of PFS estimates and MRD rates. However, RB can achieve a deep remission and could be a platform for future trials in MCL .     

Demodicidosis simulating acute graft‐versus‐host disease after allogeneic stem cell transplantation in one patient with acute lymphoblastic leukemia

One important differential diagnosis of facial erythema in a patient receiving an allogeneic bone marrow transplant (BMT) is acute graft‐versus‐host disease (GVHD). Demodex folliculorum has been rarely implicated in the development of facial rashes in immunosuppressed patients, including BMT recipients. We report the case of a patient, suffering from acute lymphoblastic leukemia, who after bone marrow transplantation developed a facial rash due to D. folliculorum mimicking GVHD. Differential diagnosis of facial rashes and demodicidosis after BMT is reviewed.     

Substantial variation in post‐engraftment infection prophylaxis and revaccination practice in autologous stem cell transplant patients

There is a paucity of evidence supporting the necessity or duration of Pneumocystis jirovecii and antiviral prophylaxis as well as revaccination following autologous stem cell transplant (ASCT). A survey aimed at evaluating these policies was distributed to 34 ASCT centres across Australasia. The 26 survey respondents demonstrated significant heterogeneity in their infection prophylaxis and revaccination strategy post‐transplant despite the availability of consensual guidelines.     

Bordetella pertussis in a four‐time kidney transplant recipient: A call for immunization programs at transplant centers

Pertussis, or whooping cough, is a highly contagious respiratory illness caused most frequently by Bordetella pertussis. Clinical presentation ranges in severity, but life‐threatening illness disproportionately affects children and immunocompromised individuals. Acellular vaccines for pertussis have been available for decades, and they are recommended throughout the lifespan. A patient who had received a kidney transplant presented with respiratory distress and dry cough as manifestations of co‐infection with B pertussis and Bordetella parapertussis/bronchiseptica. The goal of this case report was to highlight the importance of immunization programs at transplant centers, which are in the unique position to care for patients both with end‐stage organ disease and in the post‐transplant setting.     

Emerging pathogen in immunocompromised hosts: Exophiala dermatitidis mycosis in graft‐versus‐host disease

Infection with the dematiaceous environmental fungus Exophiala, an emerging pathogen in immunocompromised individuals, poses a diagnostic and therapeutic challenge. Herein, we report the first Exophiala dermatitidis fungemia case, to our knowledge, in an allogeneic hematopoietic stem cell transplant patient with graft‐versus‐host disease, expanding the clinical setting where Exophiala species mycosis should be suspected.     

TEMPORARY USE OF A NEW FULLY‐COVERED SELF‐EXPANDING METAL STENT FOR THE MANAGEMENT OF POST‐ESOPHAGECTOMY STRICTURES

Perioperative morbidity rates following esophagectomy for esophageal cancer remain quite high (26–41%) even at high‐volume centers. Complications may include stricture at the esophagogastric (EG) anastomosis, as well as tracheo‐esophageal or tracheo‐gastric fistula formation. Fully‐covered self‐expanding metal stents (FCSEMS) have only recently been described for use in benign esophageal disease. The use of FCSEMS for the management of postoperative complications following esophagectomy has not been well studied. We report our observations in three consecutive patients that underwent placement and subsequent removal of a new, fully‐covered metal stent (Wallflex^® esophageal stent) for treatment of dysphagia due to a persistent stricture at the EG anastomosis.     

Haematopoietic stem cell transplantation for sickle cell disease – current practice and new approaches

Sickle cell disease is an inherited disorder that affects over 5 million people worldwide. Current maintenance therapy has been successful in reducing complications and enhancing life expectancy; yet subclinical complications persist. To date, allogeneic haematopoietic stem cell transplant (HSCT) remains the only available curative therapy for sickle cell disease. With declining incidences of rejection and transplant‐ related mortality, disease‐free survival after human leucocyte antigen‐identical sibling transplant exceeds 90%. However, the majority of individuals with sickle cell disease do not have an human leucocyte antigen (HLA)‐identical sibling; therefore, research is expanding to focus on new approaches to alternative donor transplant. Advances in supportive care and conditioning regimens have led to expansion of the pool of donors to unrelated donors and haploidentical donors. Challenges remain in improving the safety and efficacy of HSCT from alternate donors. Early results from gene therapy may provide another curative option in patients with sickle cell disease. These approaches show early promise, but larger, longitudinal studies are needed to better determine the optimal clinical circumstances for transplant in sickle cell disease.     

Outcomes of MYC‐associated lymphomas after R‐CHOP with and without consolidative autologous stem cell transplant: subset analysis of randomized trial intergroup SWOG S9704

Double hit lymphoma (DHL) and double protein‐expressing (MYC, BCL2) lymphomas (DPL) fare poorly with R‐CHOP (rituximab + cyclophosphamide, doxorubicin, vincristine, prednisolone); consolidative autologous stem cell transplant (ASCT) may improve outcomes. S9704, a phase III randomized study of CHOP +/?R with or without ASCT enabled evaluation of intensive consolidation. Immunohistochemistry (IHC) identified 27 of 198 patients (13·6%) with MYC overexpression; 20 (74%) harboured concurrent BCL2 overexpression. Four had DHL and 16 had DPL only. With median 127 months follow‐up, there is a trend favouring outcomes after ASCT in DPL and MYC protein overexpressing patients, whereas all DHL patients have died irrespective of ASCT.     

A cluster of donor‐derived Cryptococcus neoformans infection affecting lung,liver, and kidney transplant recipients: Case report and review of literature

Donor‐derived infections (DDIs) are a very rare but potentially devastating complication of solid organ transplantation. Here we present a cluster of proven donor‐derived cryptococcal infection in the kidney, liver, and lung recipients from a single donor. Remarkably, the onset of illness in the kidney and liver recipients occurred more than 8‐12 weeks after transplantation, which is beyond the incubation period previously reported for donor‐derived cryptococcosis. DDI should always be considered in the differential diagnosis of transplant recipients admitted with febrile illness, even when presenting beyond the first month post‐transplant. Communication between reference laboratories, transplant centers, and organ procurement organizations is critical to improve outcomes.