Suzuki Yamato, Oishi Hisashi, Matsuda Yasushi, Noda Masafumi, Kumata Sakiko, Hayasaka Kazuki, Okada Yoshinori
Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan.
Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan.
Transplant Proc. 2021 May;53(4):1375-1378. doi: 10.1016/j.transproceed.2021.02.002. Epub 2021 Mar 8.
Infections caused by the Scedosporium genus have become recognized as a fatal complication after lung transplantation in Europe and Australia, but the reports have been rare from Asian countries including Japan. We present a case of pneumonia caused by a mixed infection of Scedosporium apiospermum (SA) and Lomentospora prolificans (LP) that developed after augmentation of immunosuppression for chronic lung allograft dysfunction (CLAD) after lung transplantation. A 13-year-old man underwent bilateral lung transplantation for pulmonary hypertension. One year after surgery, he was treated with a series of augmented immunosuppressive therapy for severe acute rejection and subsequent CLAD. Three months following the first steroid pulse therapy, his serum β-D-glucan elevated without any sign of fungal infection by other tests. The serum β-D-glucan once returned to a normal level by empirical administration of micafungin; however, the patient's condition worsened again by discontinuation of it. He did not recover by restarting micafungin, and computed tomography (CT) scans eventually demonstrated new infiltrates in his lung field 6 weeks after the elevation of serum β-D-glucan. Microscopic findings of transbronchial lung biopsy specimens showed filamentous fungi, and the culture of bronchoalveolar lavage fluid revealed the growth of SA and LP. Despite subsequent voriconazole administration, he died 14 days after the start of voriconazole. Early and aggressive inspection including bronchoscopy should be performed for the diagnosis of Scedosporium infection in immunocompromised patients, even if CT scans and sputum culture show no evidence of infection.
在欧洲和澳大利亚，枝孢霉属引起的感染已被公认为肺移植后的致命并发症，但包括日本在内的亚洲国家报告却很少。我们报告一例肺移植后因慢性肺移植功能障碍（CLAD）强化免疫抑制后发生的由伪阿利什霉（SA）和多育镰孢（LP）混合感染引起的肺炎病例。一名13岁男性因肺动脉高压接受了双侧肺移植。术后一年，他因严重急性排斥反应及随后的CLAD接受了一系列强化免疫抑制治疗。首次类固醇冲击治疗三个月后，他的血清β - D - 葡聚糖升高，而其他检查未发现真菌感染迹象。通过经验性使用米卡芬净，血清β - D - 葡聚糖曾恢复到正常水平；然而，停药后患者病情再次恶化。重新使用米卡芬净后他并未康复，血清β - D - 葡聚糖升高6周后，计算机断层扫描（CT）最终显示其肺野出现新的浸润影。经支气管肺活检标本的显微镜检查发现丝状真菌，支气管肺泡灌洗液培养显示有SA和LP生长。尽管随后给予伏立康唑治疗，但他在开始使用伏立康唑14天后死亡。对于免疫功能低下患者，即使CT扫描和痰培养未显示感染证据，也应进行包括支气管镜检查在内的早期积极检查以诊断枝孢霉感染。
