Status:
Ready to upload
Record number:
1806
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
This is the first reported case of presumptive donor derived Talaromyces marnefii infection by bilateral lung transplantation, so that we are unable to describe the estimated frequency.
Time to detection:
4 months
Alerting signals, symptoms, evidence of occurrence:
The recipient received a 3 month course of inhaled amphotericin per routine prophylactic protocol and valganciclovir (CMV IgG donor positive and recipient negative). Four months after transplant and 26 days following discontinuation of inhaled amphoB, the recipient developed fever, anorexia, fatigue, lymphadenopathy, oral ulcers, diarrhea and abdominal pain with severe B and T cell lymphopenia, an elevated C-reactive protein and initial normal abdominal ultrasound and CT of the abdomen. Of note, the CT scan of the chest showed bulky mediastinal and right hilar adenopathy and right pulmonary nodule with compression of the bronchus intermedius consistent with his lung transplantation. A PET CT showed increased uptake in the adenopathy. Patient developed late stage primary CMV disease after a 3 month course of CMV prophylaxis with valganciclovir and was treated with ganciclovir. Blood cultures revealed growth of fungal hyphae, identified phenotypically and confirmed by molecular sequence analysis as Talaromyces marneffi. Patient responded to intravenous liposomal amphotericin-B and received 6 months of oral voriconazole maintenance.
Demonstration of imputability or root cause:
The recipient thoracic lymphonode and blood cultures were positive for Talaromyces spp with no history of travel to an endemic area (recipient from Belgium). The donor was also from Belgium but had travelled to Myanmar 3 months prior to donation, which may have been adequate timing to develop active disease; no culture performed on donor samples. Donor was likely to have acquired the infection during his 20 day travel to Myanmar and developed latent pulmonary infection. The other recipients (kidney, liver, pancreatic cells) of organs from the same donor did not develop infection.
Imputability grade:
2 Probable
Groups audience:
Keywords:
Suggest new keywords:
Penicillinosis, Talaroymyces marneffei
voriconazole,
Reference attachment:
Suggest references:
First-in-man observation of Talaromyces marneffei-transmission by organ transplantation. Hermans F et al. Mycoses. 2017 Mar;60(3):213-217.
Note:
One concern is that this lung transplant recipient received only 3 months of valganciclovir for CMV prophylaxis despite the CMV mismatch and history of lung transplantation which would require a longer course of valganciclovir prophylaxis (minimum of 6 months). If possible to add, I would add the following - The 3 month course of valganciclovir is not considered standard of care for CMV mismatch (CMV IgG donor positive/recipient negative) and a longer course of valganciclovir with a minimum of 6 months should be considered.
Expert comments for publication:
This case illustrates the importance of a thorough donor history, including travel. T. marneffei is endemic in South East Asia. Most patients with penicilliosis present with symptoms related to infection of the reticuloendothelial system, including generalised lymphadenopathy, hepatomegaly and splenomegaly. Initial presenting features of the disease are usually non-specific, like fever, anaemia and weight loss. Molluscum contagiosum-like skin lesions are seen in most patients, and may be the best clue to diagnosis. Patients may also present with various respiratory, gastrointestinal and neurological symptoms. Mortality of untreated T. marneffei infection is reported to be 100%. Treatment of choice is intravenous amphotericin-B followed by maintenance with itraconazole or voriconazole. The importance of confirming identification of unusual pathogens is also shown in this case.