Outcome of Lung Transplantation in Patients With Mycetomas

doi:10.1378/chest.121.1.128

Chest

Volume 121, Issue 1, January 2002, Pages 128-134

https://doi.org/10.1378/chest.121.1.128 Get rights and content

Background

Lung transplantation has become an acceptable treatment option for many end-stage lung diseases. Pulmonary mycetomas are found in patients with end-stage lung diseases, especially sarcoidosis. The clinical course and long-term outcome of these patients after transplantation remains unknown.

Methods

We reviewed retrospectively the pathology reports of the explanted lungs from all lung and heart-lung transplantations performed at our institution between January 20, 1992, and June 26, 2000. Patients were included in our study if mycetomas were present on the specimens. Information on transplant date and type, diagnosis, information on antifungal therapy and fungal infections pretransplant and posttransplant, and clinical course after transplantation was recorded.

Results

Mycetomas were present in 3.0% of transplant recipients (9 of 303 patients). The underlying pulmonary diagnoses were sarcoidosis (six patients), and emphysema, idiopathic pulmonary fibrosis, and pneumoconiosis (one patient each). Seven patients received bilateral lung transplants, one patient received a heart/lung transplant, and one patient received a single lung transplant. Aspergillus was isolated from culture in five patients pretransplant and from five patients posttransplant. Six patients received treatment with itraconazole, or IV or inhaled amphotericin B prior to transplantation. All patients who survived transplantation received posttransplant antifungal therapy. Four patients died in the first month after transplantation. Two patients died at 17 months and 24 months posttransplant, respectively; one patient received a second transplant 30 months later; and two patients are alive and free from fungal infections 17 months and 18 months, respectively, after transplantation. All of the medium-term survivors received lengthy therapy with inhaled and systemic amphotericin B and itraconazole before and after transplantation.

Conclusions

Lung transplant recipients with mycetomas have significantly reduced posttransplant survival. Careful selection of patients and aggressive antifungal therapies before and after transplantation have led to improved outcomes in patients with mycetomas. Additional research is needed to define the best therapeutic strategy for these patients during transplantation.

Section snippets

Materials and Methods

We performed a retrospective review of the pathology reports of the explanted lungs of all patients undergoing lung or heart/lung transplantation in our institution between January 10, 1992, and June 26, 2000. Although mycetomas are considered a relative contraindication to lung transplantation in our institution, we evaluate these patients on a case-by-case basis. Patients were included in the current analyses if mycetomas were found on examination of the explanted lungs. A typical specimen

Results

There were 16 heart/lung transplants, 142 bilateral lung transplants, 143 single lung transplants, and 2 living-related lobar transplants for a total of 303 transplant operations. The pretransplant diagnoses were as follows: COPD (143 patients, 47.2%), cystic fibrosis or bronchiectasis (69 patients, 22.8%), pulmonary fibrosis (34 patients, 11.2%), primary pulmonary hypertension (19 patients, 6.3%), sarcoidosis (13 patients, 4.3%), congenital heart disease (12 patients, 4.0%), and other (13

Discussion

The presence of mycetomas in the lungs of patients undergoing lung transplantation is predictive of a poor posttransplant outcome. Mycetomas were not very common in our transplant population, despite a relatively higher rate of diagnosis of sarcoid compared to that of the International Registry (4.3% vs 1 to 2%, respectively).¹⁵ Early posttransplant death was very common in this series, but invasive fungal infection was the cause of death in only one patient. Therefore, it is possible that

References (19)

DKC Cooper et al.
Report of the Xenotransplantation Advisory Committee of the International Society of Heart and Lung Transplantation: the present status of xenotransplantation and its potential role in the treatment of end-stage cardiac and pulmonary diseases
J Heart Lung Transplant
(2000)
RC Daly et al.
Pulmonary aspergilloma: results of surgical treatment
Thorac Cardiovasc Surg
(1986)
JW Battaglini et al.
Surgical management of symptomatic pulmonary aspergilloma
Ann Thorac Surg
(1985)
G Massard et al.
Pleuropulmonary aspergilloma: clinical spectrum and results of surgical treatment
Ann Thorac Surg
(1992)
RG Barbers
Role of transplantation (lung, liver and heart) in sarcoidosis
Clin Chest Med
(1997)
J Dubois et al.
The physiologic effects of inhaled amphotericin B
Chest
(1995)
SM Arcasoy et al.
Lung transplantation
N Engl J Med
(1999)
EP Trulock
Lung transplantation
Am J Respir Crit Care Med
(1997)
MA Judson
Lung transplantation for pulmonary sarcoidosis
Eur Respir J
(1998)

There are more references available in the full text version of this article.

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Mycetomas are uncommon in lung transplant recipients. Prior studies have shown increased mortality associated with mycetoma in lung transplant recipients (LTR). We reviewed our center's experience in outcome of LTRs with pre -or post-transplant mycetoma.
We retrospectively reviewed electronic health records of LTRs performed at our institute between January 1, 2013 to December 31, 2020.
Mycetoma was present in less than 1 percent of LTR patients (7/1086). Mean age at the time of the transplant was 65 years. Idiopathic pulmonary fibrosis (5/7), interstitial lung disease (1/7), and sarcoidosis (1/7) were underlying pulmonary diagnoses. Seventy-one percent (5/7) received single lung transplant and 29% received double lung transplant. Seventy-one percent had negative serum galactomannan vs 29% (2/7) of patients who had positive serum galactomannan (one post and one pre). Fifty-seven percent had positive bronchoalveolar aspergillus galactomannan (23% had negative). A total of 42% (3/7) were found to have mycetoma before transplant and 58% (4/7) had mycetoma post transplant. Chest computed tomography findings in all patients were consistent with mycetoma.
In our cohort of patients, mycetoma was not found to be the primary cause of death if diagnosed pre transplant. Transplant recipients with mycetoma pre transplant did not develop invasive fungal infection or mycetoma post transplant. Careful evaluation of lung transplant candidates with mycetoma is critical. Further studies are needed to determine optimal duration of antifungal therapy and to determine if surgical resection may be needed to manage post-lung transplant mycetoma.
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Lung transplantation in pulmonary sarcoidosis
2023, Journal of Autoimmunity
Sarcoidosis is a systemic inflammatory disease of unknown etiology and variable clinical course. Pulmonary sarcoidosis is the most common presentation and accounts for most morbidity and mortality related to sarcoidosis. While sarcoidosis generally has good outcomes, few patients experience chronic disease. A minority of patients progress to a specific phenotype of sarcoidosis referred to advanced pulmonary sarcoidosis (APS) which includes advanced fibrosis, pulmonary hypertension and respiratory failure, leading to high morbidity and mortality. In patients with advanced disease despite medical therapy, lung transplantation may be the last viable option for improvement in quality of life. Though post-transplant survival is similar to that of other end-stage lung diseases, it is imperative that patients are evaluated and referred early to transplant centers with experience in APS. A multidisciplinary approach and clinical experience are crucial in detecting the optimal timing of referral, initiating comprehensive transplantation evaluation and listing, discussing surgical approach, and managing perioperative and post-transplant care. This review article seeks to address these aspects of lung transplantation in APS.
Granulomatous fungal and non-tuberculous mycobacterial infestation complicating chronic lung disease: Outcomes in patients undergoing lung transplantation
2021, Annals of Diagnostic Pathology
Citation Excerpt :
One such complication is a granulomatous infection superimposed on chronic lung disease. Lung transplant recipients with a granulomatous fungal or a mycobacterial infection have significantly reduced post-transplant survival rates [8]. However, careful patient selection and aggressive antifungal therapies have led to improved outcomes in this patient group [8].
Granulomatous infections are common in patients with chronic lung disease. We aim to study the incidence and clinicopathological features of granulomatous infections in a cohort of patients undergoing lung transplantation for end-stage chronic lung disease.
Pathology reports of 50 explanted native lungs of patients who underwent lung transplantation since 2015 at our institution were reviewed. Four cases with granulomatous lesions were identified. Correlation was made with clinical findings in the 4 cases.
The granulomatous infections include non-necrotizing cryptococcal pneumonitis (case 1), necrotizing pneumonia due to Scedosporium sp. and Mycobacterium avium Complex (MAC) (Cases 2 and 3), and invasive Aspergillus pneumonia (Case 4). One patient received pre-transplant fungal prophylaxis (Case 4). Post-transplant infectious complications included invasive (Cases 2 and 4) and non-invasive (Case 1) fungal infections and bacterial pneumonia (Cases 1 and 2). Two patients (Cases 3 and 4) developed acute cellular rejection (ACR) in the first 30 days. The third patient (Case 1) was identified with ACR in the 9 months post-transplant and chronic lung allograft dysfunction at 29 months. In terms of mortality, 1 patient (Case 1) died at 30 months post-transplant from pseudomonal sepsis and chronic graft failure. Two patients with invasive fungal infections (Cases 2 and 4) are on secondary prophylaxis and doing well. One patient (Case 3) remains infection-free and on MAC prophylaxis.
In our case series, patients with chronic lung diseases with superimposed granulomatous infestations frequently experienced post-transplant complications. These include invasive infections and repeat ACRs that predispose patients to chronic graft dysfunction. Pre- and post-transplant antifungal prophylaxis reduces fungal load and complication risk post-transplant.
Pulmonary sarcoidosis
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Sarcoidosis is a granulomatous disease of unknown cause, occurs worldwide and has a highly variable prevalence. The disease is typically dominant in the lungs, although it can affect virtually any organ and is unpredictable in its clinical course. The severity of pulmonary sarcoidosis ranges from incidentally discovered radiographic abnormalities in asymptomatic patients to a chronic progressive disease that is refractory to treatment. Mortality from sarcoidosis appears to have increased in the past three decades, with respiratory failure being the most common cause of sarcoidosis-related death. Pulmonary fibrosis, extensive disease on high-resolution chest CT, impaired lung function, and pulmonary hypertension are well established predictors of poor clinical outcomes. In patients who need systemic therapy to control their disease, corticosteroids are the most commonly used first-line treatment, with antimetabolites generally representing an alternative for patients who are unresponsive to corticosteroids or who cannot tolerate them. Indeed, corticosteroid therapy is associated with toxic effects that correlate with both the cumulative dose and duration of treatment. The scarcity of truly effective therapies and shortage of reliable predictors of the unpredictable development of disease in individual patients greatly contribute to making sarcoidosis such a difficult disease to manage.
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Nonpharmacologic management is an important aspect of personalized care in sarcoidosis. Immune suppression is the focus of pharmacologic therapy for preventing disease progression, but nonpharmacologic interventions can improve the quality of life and outcomes for patients who develop fibrosis and complications resulting from fibrotic lung disease. This chapter explores both complimentary and autonomous therapeutic options and approaches to manage severe sarcoidosis.

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Clinical InvestigationsFungusOutcome of Lung Transplantation in Patients With Mycetomas

Background

Methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

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Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Clin Chest Med

Chest

Lung transplantation

N Engl J Med

Lung transplantation

Am J Respir Crit Care Med

Lung transplantation for pulmonary sarcoidosis

Eur Respir J

Clinical Investigations
Fungus
Outcome of Lung Transplantation in Patients With Mycetomas