Page 1586 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 115: The Transplant Patient 1105

patients, classic symptoms of infection are often blunted, causing them to TABLE 115-17 Approach to Bilateral Airspace Disease and Altered Level
present at a later time when the infectious process is more disseminated. of Consciousness in a Transplant Recipient
Furthermore, alternative causes of fever such as rejection can obscure
the clinical picture leading to empiric and recurrent antimicrobial use Bilateral Airspace Disease Decreased Level of Consciousness
when none may be warranted, and the frequent use of broad-spectrum Bacterial pneumonia Bacterial meningitis (including Listeria)
antimicrobials may lead to the development of resistant organisms. a b
Multiple drug interactions exist between certain antimicrobials and Viral/atypical/fungal/PJP pneumonia Viral meningitis (including JC virus,
c
immunosuppressive therapies. Knowledge of these potential interactions HSV )
is imperative to prevent potential adverse side effects that could arise. The Drug-induced hypersensitivity reaction (sirolimus) Fungal meningitis (including
side effects of immunosuppressive agents can sometimes be mistaken Cryptococcus neoformans)
for infectious processes such as the drug-induced pneumonitis due to Pulmonary edema secondary to left ventricular Calcineurin inhibitors
sirolimus, which can often present like community-acquired pneumonia. failure
Table 115-17 outlines the differential for common conditions in the
immunosuppressed population and the infections and noninfectious Noncardiogenic pulmonary edema (ARDS due to Central nervous system lymphoma
local infectious or distal infections etiologies)
processes that should be considered in a transplant recipient.
In the initial post-operative phase, patients are particularly suscep- Metabolic s/e immunosuppression (renal
tible to nosocomial bacterial and, less commonly, fungal infections. failure, hyperosmotic nonketotic acidosis)
With time, the effects of sustained immunosuppression are seen with Hyperammonemia
greater risk for opportunistic infections. This risk may be augmented a Pneumocystis jiroveci pneumonia.
in patients who have had a more complicated post-operative course, b
punctuated by episodes of acute rejection necessitating intensification Papovavirus.
of their immunosuppression. In addition, modification in duration of c Herpes simplex virus.
prophylaxis may simply defer infection to later in the patient’s course
(eg, CMV). Later, as the intensity of immunosuppression is reduced, complications according to the time that has elapsed since the original
opportunistic infections tend to decrease in prevalence and are over- procedure (see Fig. 115-7).
shadowed by complications such as chronic rejection, and malignancies
such as posttransplant lymphoproliferative disorders. Several authors Infections Occurring in the First Posttransplant Month: In the first month
have proposed an approach that classifies the most likely infectious after transplant, most infections are similar to those encountered

Conventional
nosocomial Unconventional or opportunistic infections Community-acquired or
infections persistent infections

Viral
HSV
Onset of CMV CMV retinitis or colitis
EBV, VZV (shingles), influenza, RSV, adenovirus
Papillomavirus, PTLD
Onset of hepatitis B or hepatitis C

Bacterial
Wound infections, catheter-related infections, pneumonia
Nocardia
Listeria, tuberculosis

Fungal
Pneumocystis
Aspergillus Cryptococcus
Candida Geographically restricted, endemic fungi
Parasitic
Strongyloides
Toxoplasma
Leishmania
Trypanosoma cruzii

0 1 2 3 4 5 6
Months after transplantation
FIGURE 115-7. Timing of infectious complications posttransplant. Usual sequence of infections after organ transplantation. Zero indicates the time of transplantation. Solid lines indicate the
most common period for the onset of infection; dotted red lines divide infectious episodes into early and late. CMV, cytomegalovirus; EBV, Epstein-Barr virus; HSV, herpes simplex virus; PTLD, post-
transplantation lymphoproliferative disease; RSV, respiratory syncytial virus; VZV, varicella-zoster virus. (Adapted with permission from Rubin RH, Wolfson JS, Cosimi AB, Tolkoff-Rubin NE. Infection in
the renal transplant recipient. Am J Med. February 1981;70(2):405-411.)

section10.indd 1105 1/20/2015 9:20:01 AM