Disseminated lomentosporiosis in a heart transplant recipient: Case report and review of the literature

• Published in: Transplant infectious disease Vol. 23; no. 4; pp. e13574 - n/a
• Main Authors: Valerio, Maricela, Vásquez, Víctor, Álvarez‐Uria, Ana, Zatarain‐Nicolás, Eduardo, Pavone, Paolo, Martínez‐Jiménez, María del Carmen, Barrio‐Gutiérrez, José María, Cuerpo, Gregorio, Guinea‐Ortega, Jesús, Vena, Antonio, Peligros‐Gómez, María Isabel, Bouza, Emilio, Muñoz, Patricia
• Format: Journal Article
• Language: English
• Published: Denmark Wiley Subscription Services, Inc 01-08-2021
• Subjects: Biopsy; Cardiovascular diseases; Case reports; Catheters; Central nervous system; Complications; Coronary artery disease; Cotrimoxazole; Disease prevention; disseminated fungal infection; Disseminated infection; Extracorporeal membrane oxygenation; Fungi; Fungicides; Ganciclovir; Health risks; Health services; Heart diseases; heart transplant; Heart transplantation; Heart transplants; Infections; Influenza B; Kidney transplantation; Literature reviews; Lomentospora prolificans; Medical instruments; Microbiology; Necropsy; Neutropenia; Oxygenation; Pancytopenia; Patients; Prophylaxis; Pseudomonas aeruginosa; Renal replacement therapy; Respiratory failure; Seizures; solid organ transplantation; Spores; Terbinafine; Transplantation; Ventricle; Voriconazole; heart transplant; solid organ transplantation; Lomentospora prolificans; disseminated fungal infection
• ISSN: 1398-2273; 1399-3062
• DOI: 10.1111/tid.13574

Background
Lomentospora prolificans (formerly S prolificans) is a saprophyte fungi that causes opportunistic infections in solid organ transplant (SOT) recipients. Resulting disseminated infections are difficult to treat and have a high mortality. Indications for antifungal prophylaxis after heart transplantation (HT) include CMV disease, reoperation, renal replacement therapy, extracorporeal membrane oxygenation (ECMO), and high environmental exposure to Aspergillus spores. However, the risk of breakthrough infections, such as Lomentosporiosis, remains a cause of concern.
Methods
We report the clinical findings, microbiology, treatment and outcome of a disseminated Lomentosporiosis in a heart transplant recipient with ECMO and antifungal prophylaxis.
Results
A 25‐year‐old male with complex grown‐up congenital heart disease (GUCHD) was admitted for HT. He presented severe post‐surgical complications including acute kidney injury and right heart and respiratory failure requiring venoarterial‐ECMO, continuous renal replacement therapy (CCRT) and later on (+14) a ventricular assist device (VAD). Ganciclovir, cotrimoxazole, and antifungal prophylaxis with anidulafungin at standard doses had been started on day + 3 post HT. The patient presented seizures (+4), pancytopenia with mild neutropenia (days + 6 to + 11), influenza B (+7), and bacteremic Pseudomonas aeruginosa ventilator associated pneumonia (VAP) (+10). On days + 14 to + 16 Lomentospora prolificans was recovered from blood cultures, broncho aspirate, catheter tip, and skin biopsy. Despite treatment with L‐AMB, voriconazole and terbinafine the patients died on day 17 after HT. Necropsy revealed disseminated infection with fungal invasion in central nervous system, heart, lung, cutaneous, and subcutaneous tissue. Broth microdilution tests demonstrated resistance to all antifungals.
Conclusions
Lomentosporiosis is a rare complication that may emerge as a breakthrough invasive fungal infection in heart transplant recipients on ECMO despite antifungal prophylaxis.