Low-dose TMP/SMX, one single or double strength tablet daily, administered for six months after transplantation has effectively reduced the incidence of post-transplant PCP. Alternative regimens are dapsone, aerosolized pentamidine, and atovaquone. Patients with ongoing significant immunosuppression, allograft rejection, and allograft dysfunction require a longer period of prophylaxis.

Endemic Mycoses

The endemic mycotic pathogens include H. capsulatum, C. immitis, Blastomyces dermatitidis, and Paracoccidiodes brasiliensis. These infections occur at any point after transplantation as a result of primary acquisition or reactivation of disease. It is unclear whether blastomycosis or paracoccidiomycosis occur at any greater frequency in transplant recipients than in the general population.

Organ recipients who reside or who have traveled to the southwestern United States or northern Mexico, and certain areas of Latin America are at risk for coccidioidomycosis. Common clinical presentations include disseminated and pulmonary infection. Patients present with nonspecific symptoms such as fever, night sweats, malaise, cough, and dyspnea. Chest radiographic findings include interstitial, alveolar, nodular, or lobar infiltrates; a miliary pattern; cavitary lesions; and hilar adenopathy. Other potential sites of infection include the blood, skin, brain, liver, urine, bone and joints, and muscle, including myocardium. The diagnosis is made by serology, histopathology, and culture. The treatment of choice is ampho-tericin B, and an alternative agent is fluconazole.

Histoplasmosis is endemic in the central United States, along the Ohio and Mississippi River Valleys, as well as many other countries. This infection usually occurs as a result of inhalation, and transmission by the allograft has been documented. Disseminated infection is the most common presentation in transplant recipients, whose symptoms are nonspecific, including fever, night sweats, nonproductive cough, headache, myalgias, and muco-cutaneous lesions. Hepatosple-nomegaly and pancytopenia may be present. Chest radiographic findings include interstitial or miliary infiltrates, focal consolidation, and hilar adenopathy. The diagnosis is made by serologic testing, direct detection of antigen is urine, histo-pathology, and culture of appropriate specimens such as respiratory tract secretions and tissue, blood, bone marrow, and other affected tissues. The treatment of choice is amphotericin B; alternative agents include the lipid-based amphotericins and itraconazole.

There are no firm recommendations for prevention of the endemic mycotic infections after transplant; some centers advocate pre-transplantation screening of at-risk candidates by serologic testing and chest radiography and azole prophylaxis for candidates with evidence of prior infection.

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