[Invasive candidiasis in a lung retransplantation recipient]

Lung-graft loss is a potential problem for the majority of lung-transplant recipients. Retransplantation could be a treatment option, despite significant morbidity and mortality due to infectious complications. The epidemiology, clinical presentation and early treatment are still the basis of the overall approach to the fungal invasive infection after repeated transplant.

This is the case of a 29 year-old woman who underwent a left lung retransplantation due to bronchiolitis obliterans syndrome and developed Candida albicans invasive disease. She received the usual prophylaxis with nebulized liposomal amphotericin B and was also treated with anidulafungin. She received corticosteroid therapy and plasma exchange as acute lung transplant rejection was suspected with subsequent progressive deterioration and death. In the culture of blood samples yeasts were isolated, later identified as C. albicans resistant to fluconazole, caspofungin and micafungin (MCI 128 μg/ml, 8 μg/ml, 4 μg/ml, respectively) and susceptible to anidulafungin and amphotericin B (MCI 0.25 μg/ml, 0.5 μg/ml, respectively).

The empirical management of acute transplant rejection with corticosteroid boluses and plasma exchange can help to spread the underlying and undiagnosed fungal infection. It is considered that an increase in the regular dose of anidulafungin is necessary after plasma exchange. To date, fungal echinocandin resistance did not seem to be a major cause for concern in the treatment of patients with invasive mycoses. However, there is increasing evidence of natural and acquired resistance resulting in life-threatening infections and clinical failure.