Chest
Volume 122, Issue 4, October 2002, Pages 1185-1191
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Clinical Investigations
Saprophytic Fungal Infections and Complications Involving the Bronchial Anastomosis Following Human Lung Transplantation

https://doi.org/10.1378/chest.122.4.1185Get rights and content

Study objective

To demonstrate an association between saprophytic fungal infections occurring at the bronchial anastomosis (BA) and the development of additional complications arising at this site.

Design

Retrospective review.

Setting

University lung transplant center.

Materials and methods

Review of all single-lung and double-lung transplant (LTX) recipients who underwent transplantation between June 1993 and December 2000. All recipients were subjected to surveillance bronchoscopy with biopsy at predetermined intervals and when clinically indicated. Bronchial wash fluid and biopsy material were examined using appropriate fungal stains and culture techniques. An infection was defined when fungal organisms were identified in tissue specimens.

Results

Fifteen saprophytic fungal infections involving the BA were identified in 61 LTX recipients (24.6%) who survived a minimum of 75 days post-transplantation. Infections were attributed to Aspergillus sp (n = 9), Candida sp (n = 2), Torulopsis sp (n = 1), and mixed flora (ie, Penicillium + Candida, two patients; and Aspergillus + Candida, one patient). Saprophytic fungal infections occurred by a median of postoperative day 35 (range, 13 to 159 days). Airway complications involving the BA ultimately developed in 11 of 61 recipients (18%). These complications included symptomatic bronchial stenosis (nine patients), bronchomalacia (one patient), and fatal hemorrhage (one patient). Bronchial complications arose in 7 of 15 recipients (46.7%) with saprophytic fungal infections of the BA in contrast to 4 of 46 (8.7%) without infections (p = 0.003, Fisher exact test). Also demonstrated was a positive correlation between anastomotic infections and bronchial complications (Φ coefficient = 0.43; p = 0.001), while logistic regression analysis revealed that the absence of anastomotic infections predicted the absence of such complications (p = 0.002). The risk of developing an additional complication following an anastomotic infection in patients with infections was five times that of those recipients without an infection (relative risk, 5.36; 95% confidence interval [CI], 1.82 to 15.79). The odds in favor of a bronchial complication following an infection were eight times greater than in those recipients without infection (odds ratio, 8.31; 95% CI, 1.96 to 35.16).

Conclusions

Following LTX, saprophytic fungal infections of the BA are associated with serious airway complications.

Section snippets

Materials and Methods

The investigation involved a retrospective review of all LTX procedures performed between June 1993 and December 2000. To allow for an interval of adequate post-transplantation surveillance, a recipient had to survive a minimum of 75 days following transplantation to be included in the study. No recipient having an infection or complication of the BA died before postoperative day 75.

As previously described, in patients undergoing single-LTX, implantation of the donor organ was achieved by

Results

During the study period, 66 transplant procedures were performed in 65 recipients. One recipient received a second single-LTX after the initial allograft was compromised by the development of obliterative bronchiolitis. Of these 65 recipients, 17 were recipients of double-LTXs and 48 were recipients of single-LTXs. Sixty-one of these recipients survived a minimum of 75 days following the transplant procedure, and these recipients comprised the study group. Of these 61 recipients, 38 were men

Discussion

The bronchial circulation, being the primary source of blood flow to the major bronchi, is disrupted during the single-LTX and double-LTX procedures. Consequently, in the early post-transplantation period the BA site is initially devascularized, which may result in the sloughing of epithelial tissue into the airway lumen. Saprophytic fungal organisms are easily airborne and thus have ready access to the airway lumen and the relatively ischemic BA. As saprophytes are organisms that obtain their

References (20)

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Supported in part by the McKelvey Fund of the Tides Foundation.

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