Complications of Lung Transplantation – Infection and Malignancies
After a lung transplant, patents are generally given drugs that will suppress the body’s natural immune system. This is to prevent the body from rejecting the new lungs.
Because the body’s immune system is being suppressed, patients may have an increased risk of infection, especially during the first six months when dosages are higher because of the increased risk of rejection.
This feature contains information on:
- Signs and symptoms of infection
- Types of infection
- Preventing infection
Signs and Symptoms of Infection
- Fever (Usually greater than 100 degrees)
- Shortness of breath
- Excessive sweating or night sweats
- Nausea, vomiting or diarrhea (more than 3 days)
- Unexplained pain in chest, throat, abdomen, or back
- Redness, swelling, or drainage at a incision site
Types of Infection
Infections may be viral, bacterial, fungal, or protozoan.
Some of the most common types of infections post-transplant are bacterial infections. Bacterial infections are caused by organisms that inhabit the skin or body cavities. These organisms rarely cause problems for persons with normal immune systems, but they may lead to infections in someone whose immune system is being suppressed.
Bacterial infections may occur at any site. If your doctor suspects that you have a bacterial infection you may have to have blood, sputum, and urine cultures and a chest X-ray. In some instances a bronchoscopy can help to isolate the cause of an infection in the lung. Depending on the cause and the severity of the infection, patients may need to take antibiotics either by mouth or intravenously.
Viral infections include CMV (cytomegalovirus) and herpes (simplex or zoster) and influenza. During the pre-transplant evaluation, testing will be done for previous exposure to CMV and herpes infections as well as hepatitis and HIV.
CMV – CMV at one point was a common infection in lung transplant patients. Modern developments of oral drugs that protect against CMV and screening tests to detect CMV in the bloodstream have significantly decreased the burden of this agent in lung transplants. Nonetheless, prevention of and screening for CMV disease remains an important element of post-transplant care. CMV in non-transplant patients, is usually a self-limited infection characterized by mild flu-like symptoms. They include:
- Fever greater than 101 degrees
- Low white blood cell count
- Muscle weakness
- Shortness of breath
- Blurry vision
- Blood in stool, diarrhea, nausea, and vomiting
More than 50 percent of Americans have had previous exposure to CMV. In a patient with a suppressed immune system, CMV may cause a more serious illness.
Patients who have previously been exposed to CMV, or whose donor had previous exposure, are treated with a combination of ganciclovir and/or vanganciclovir for several months or longer after transplant. Antibodies against CMV are contained in a purified blood product preparation called cytogam may also be useful in the management of CMV disease.
Herpes – Herpes is present in as much as 40 percent of the transplant population. The virus commonly affects people during childhood. Symptoms may include fever blisters around the mouth, in the esophagus, the genital area or anus.
After the blisters have disappeared, the virus remains latent on the nerve roots. It may appear later as skin eruption called shingles and cause painful blisters along nerve pathways on the surface of the skin, most commonly on the chest, flank, and face. Avoid persons with active chicken pox because the virus may cause a more severe infection in recipients who never had exposure, or may cause shingles in patients who had chicken pox previously. Herpes infections are treated with acyclovir.
Fungal infections, such as candida, aspergillosis, and histoplasmosis may range from mild (thrush) to life threatening.
Candida – Candida is yeast that grows in warm moist areas of the body, such as the mouth, arm pits, groin, and genital area. It is also known as thrush or monilla. When it occurs in the mouth, candida can be treated with Mycostatin mouthwash or Mycolex troches; when it occurs on the skin it can be treated with lotions. If it occurs in the body it may require treatment with oral or intravenous anti-fungal medicines.
Aspergillosis – Aspergillosis may be contracted by breathing fungal spores in damp musty places, such as attics, basements, barns, construction sites, freshly dug gardens or mowed grass. Take care to avoid these areas or, if necessary, wear a mask in those environments. The development of oral antifungal medications with activity against aspergillus have dramatically decreased the incidence of these infections in lung transplant patients.
Histoplasmosis – Histoplasmosis is an air-borne fungal disease found in bird droppings. Avoid exposure to bird droppings, especially in enclosed areas.
Pneumocystis – Pneumocystis is a pulmonary infection that occurs primarily in patients who are immunosuppressed. Its symptoms include cough, fever, general discomfort, and shortness of breath.
The most important thing to remember is to use common sense. Good hand washing, cleanliness, and personal hygiene help prevent infection.
While you are in the hospital, the ICU may have special procedures and guidelines for preventing infection:
- Visitors may have to wash their hands and put on a mask prior to entering your room.
- If you are moved to a regular nursing floor a mask may not be necessary for visitors.
- People with colds or other signs of infection should avoid visiting until they are healthy.
- You may need to wear a mask when out of the room to avoid contracting infections from other patients or exposure to fungal spores from hospital construction areas.
Other precautions to take:
- Avoid fresh fruit, vegetables, and fresh flowers while in the hospital.
- After hospital discharge avoid anyone who had a cold or active infection.
- During the first three months avoid large crowds (e.g. church, sporting events, concerts).
- Thoroughly wash fresh fruits and vegetables before eating.
- Avoid eating raw oysters, raw shellfish, or raw fish.
- Eggs should be fully cooked and chicken and pork should be well done.
- Avoid mowing the lawn, digging in the garden and being near construction sites. These activities increase your exposure to fungal infections
- If you enjoy fishing, use caution with fishhooks, fillet knives and fish fins. Wear gloves when you handle these items.
- If you have pets, someone else should change the cAT litter or birdcage liners.
- Do not let your medications run out. Some pharmacies need to special order your immunosuppression medicines ahead of time.
- You can take influenza, pneumonia and hepatitis vaccines 6 months after transplant. In general you should not receive “live virus” vaccines or be in contact with persons who recently received a live virus vaccine*, which may trigger an infection in an immunosuppressed patient.
Guide to Vaccines
*Live Virus Vaccines include:
- Varicella (chicken pox)
- Small Pox
Inactivated Virus Vaccines
- Hepatitis B
- Inactivated Bacterial Vaccines
Transplant patients are more susceptible to malignant tumors (cancers) than the general population. The body normally tries to defend against malignant cells via its immune system. However, because the immune system is being suppressed to preserve the transplanted lungs, malignant cells may escape detection by the immune system and develop into a tumor.
Skin cancers – Skin cancers are the most common tumor in transplant patients, and sun exposure is the major risk factor. Always wear sunscreen on exposed areas when outside in bright sunlight. Wear a hat when out in the sun for long periods of time. Routine dermatology evaluations are often suggested in transplant recipients.
Lymphomas – Lymphomas occur with greater frequency in transplant patients. They may be first noticed as an enlarged lymph node on an X-ray. Some lymphomas or lymphoma- like syndromes especially Post Transplant Lymphoproliferative Disorder (PTLD) may be associated with Epstein Barr virus infections. Symptoms may include fever, malaise, weight loss, poor appetite or sweating.
This information originally appeared in the University Hospitals Lung Transplantation Patient Handbook, and was adapted for use on NetWellness with permission, 2007.
More articles about Lung Transplantation:
- Before Transplantation – Getting on the Transplant List
- Lung Transplant Surgery and Recovery
- Medications for Lung Transplant Patients
- Complications of Lung Transplantation – Rejection
For more information:
Go to the Lung Transplantation health topic.