Approaches to fungal diagnosis in transplantation

The diagnosis of invasive fungal infection in patients undergoing solid organ or bone marrow transplantation remains a significant clinical challenge. Consideration of the epidemiology of these infections and host risk factors may be an important clue to a specific fungal diagnosis. Despite extensive investigation on methods such as serologic techniques to improve the rapid diagnosis of these infections, the diagnosis of invasive mycoses remains largely dependent on clinical presentation. For example, the signs and symptoms that result from angioinvasion of fungal organisms include pleuritic chest pain or hemoptysis. In a high-risk patient these findings can be important clues to invasive fungal infection. Cultures of opportunistic fungi in certain settings, such as Aspergillus in respiratory samples from immunosuppressed patients, may be associated with infection. Radiographic findings can also be useful to establish a diagnosis of infection. In patients with invasive aspergillosis as well as other angioinvasive moulds, chest CT scans may demonstrate lesions that are not visible on plain radiographs. Serodiagnosis of these infections remains largely investigational. Microbiological antifungal resistance has increasingly been reported, but in patients at high risk for serious fungal infection, including patients undergoing bone marrow and organ transplantation, antifungal resistance remains uncommon, particularly in Candida albicans. Higher doses of azoles should be used to treat patients with infections due to less susceptible yeasts and those with more serious infection. Prompt recognition of fungal infection combined with intensive antifungal therapy is needed for successful therapy.