Prophylaxis in Lung Transplant Recipients Free

To theEditor—We read the article by Truong and colleagues with great interest [1]. Our lung transplant program in Arizona has also adopted a universal lifelong fungal prophylaxis protocol with similarly excellent results in reducing incident coccidioidomycosis among lung transplant recipients.

Despite the excellent tolerance reported by Truong et al, challenges may arise for patients who need to stop prophylaxis due to side effects or financial concerns or for patients who leave the endemic area and wish to discontinue prophylaxis. Moreover, many patients who receive transplants at centers elsewhere and relocate to regions endemic for coccidioidomycosis will not be on a fungal prophylaxis regimen as recommendations regarding prophylaxis vary based on local epidemiology and time post-transplant [2, 3]. Current American Society of Transplantation guidelines recommend 6–12 months of Coccidioides prophylaxis for recipients living in endemic regions. Risk stratification for these patient populations may be helpful in determining the safety of withholding prophylaxis. Unfortunately, current commonly used diagnostic testing (Coccidioides serology) is not sensitive for remote infection [4, 5], which may reactivate and disseminate in the setting of immunosuppression. Skin testing is an attractive alternative but is cumbersome, insensitive, and infrequently used [6].

Lung transplant recipients are highly immunosuppressed and may be unique, but lifelong prophylaxis may not be a feasible strategy for all patients. Development of a cytokine release assay specific to Coccidioides, similar to the interferon-gamma release assays currently used for latent tuberculosis, could prove clinically useful [7]. Such assays hold the promise of identifying patients with remote coccidioidomycosis who are at risk for developing disease with initiation of immunosuppression. For patients who receive transplants at centers in endemic areas who choose to relocate to other areas of the country, testing may facilitate the safe discontinuation of lifelong prophylaxis. Due to frequent travel in and out of endemic areas, patients who receive transplant at centers outside of that region are also at risk for coccidioidomycosis, a disease that has a broadening endemic area [8]. A reliable and easy to use assay to assess the T-cell response to Coccidioides could be used to identify patients with prior coccidioidomycosis and allow transplant centers outside endemic regions to implement appropriately timed fungal prophylaxis. Such an assay may also be useful in guiding prophylaxis strategies for patients at risk for reactivation of disease who receive treatment with biologic agents. A personalized approach for all immunosuppressed patients with a simpler, accurate test for cellular immunity is ideal and should remain a future research priority.

Note

Potential conflicts of interest. S. C. reports grants or contracts from Investigator Initiated Studies Boehringer Ingelheim; consulting fees from Boehringer Ingelheim and Veracyte; and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Boehringer Ingelheim and Veracyte. K. S. K. reports a grant from the National Institutes of Health [NIH] National Institute of Allergy and Infectious Diseases. J. M. reports a grant or contract as a co-investigator from NIH NIAID. All other authors report no potential conflicts.

All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

References