Multiorgan Transplant Infectious Diseases Division, University of Toronto, Toronto, Ontario, Canada.
Semin Respir Crit Care Med. 2010 Apr;31(2):222-33. doi: 10.1055/s-0030-1249118. Epub 2010 Mar 30.
The landscape of fungal infections in lung transplant recipients has significantly changed over the course of time. The initial predominance of CANDIDA species has given way to the prominence of ASPERGILLUS species in the current era followed by other mold infections, namely, SCEDOSPORIUM and Zygomycetes, which are emerging as newer pathogens. CRYPTOCOCCUS NEOFORMANS is another important pathogen responsible for the morbidity in lung transplant recipients. The use of widespread antifungal prophylaxis directed against the mold infections has resulted in delayed onset of invasive aspergillosis in lung transplant recipients. In recent studies cumulative incidence rate of invasive aspergillosis was noted to be 2.4% at 12 months. Invasive mold infections in lung transplant may present as tracheobronchitis, invasive pulmonary infections, or disseminated disease. Invasive pulmonary infections are now the most common manifestations of mold infections, followed by tracheobronchitis. Pre- or posttransplant ASPERGILLUS colonization, along with preceding cytomegalovirus infections, hypogammaglobulinemia, and single-lung transplants are considered significant risk factors for invasive aspergillosis. Recently posttransplant colonization has been implicated in the development of bronchiolitis obliterans syndrome. The appropriate antimold prophylaxis strategy, by the use of either voriconazole or inhaled amphotericin, remains to be fully determined. Advances in the diagnosis and treatment of invasive aspergillosis have resulted in significant decreases in mortality. The risk factors for other mold infections such as SCEDOSPORIUM or Zygomycetes are being elucidated. Infections with these organisms, however, carry mortality up to 80%. The current article reviews the changes in the epidemiology of invasive molds and CRYPTOCOCCUS infections and other emerging fungal pathogens and highlights the controversies surrounding antifungal prophylaxis in lung transplant recipients.
肺移植受者真菌感染的情况随着时间的推移发生了显著变化。在当前时期，念珠菌属（CANDIDA）种的最初优势让位于曲霉菌属（ASPERGILLUS）种，随后是其他霉菌感染，如枝孢菌属（SCEDOSPORIUM）和接合菌（Zygomycetes），它们作为新的病原体出现。新型隐球菌（CRYPTTOCOCCUS NEOFORMANS）也是导致肺移植受者发病的重要病原体之一。针对霉菌感染广泛使用的抗真菌预防治疗导致肺移植受者侵袭性曲霉菌病的发病时间延迟。在最近的研究中，侵袭性曲霉菌病的累积发病率在 12 个月时为 2.4%。肺移植后侵袭性霉菌感染可表现为气管支气管炎、侵袭性肺部感染或播散性疾病。侵袭性肺部感染现在是霉菌感染的最常见表现，其次是气管支气管炎。移植前或移植后曲霉菌定植，以及先前的巨细胞病毒感染、低丙种球蛋白血症和单肺移植被认为是侵袭性曲霉菌病的重要危险因素。最近，移植后定植被认为与闭塞性细支气管炎综合征的发展有关。使用伏立康唑或吸入性两性霉素的适当抗霉菌预防策略仍有待充分确定。侵袭性曲霉菌病的诊断和治疗进展导致死亡率显著下降。正在阐明枝孢菌属或接合菌等其他霉菌感染的危险因素。然而，这些病原体的感染死亡率高达 80%。本文综述了侵袭性霉菌和隐球菌感染以及其他新兴真菌病原体的流行病学变化，并强调了肺移植受者抗真菌预防治疗中的争议。
