Case Presentation: The patient is a 64-year-old male, history of ischemic cardiomyopathy, chronic right ventricular failure, arrhythmia, and new infarcts, status post cardiac transplant. While recovering in the cardiac ICU, the patient started experiencing confusion and personality changes, and was unable to recognize his mom. On CT scan, the patient was shown to have a brain abscess, and the patient was started on IV amphotericin. The CSF culture grew Scedosporium, so the treatment regimen was changed to voriconazole and microfungin. The patient continued to deteriorate, even with antibiotics, and subsequently developed pericardial tamponade, which also grew Scedosporium on culture. The patient died in surgery, due to disseminated intravascular coagulation, persistent hypotension, and uncontrolled bleeding.
Discussion: Infections are a known risk after heart transplant, due to the immunosuppression that is required for transplant to be successful. Culprits often include known organisms such as S. aureus, S. epidermidis, Pseudomonas aeruginosa, Candida, and Mycoplasma hominis. These early infections often affect the wound and the mediastinum. In less than 3% of patients, the infection can be in the CNS. In those instances, infection is most commonly cryptococcal meningitis, progressive multifocal leukoencephalopathy, varicella-zoster virus encephalitis, and aspergillus fumigatus. Scedosporium spp. is a fungus that can colonize the bronchopulmonary tree. Scedosporium infections are emerging to be a concern in immunocompromised patients and has been found to infect lungs, sinuses, bones, joints, eyes, and brain. The infections can become disseminated, especially in the immunocompromised. There are limited studies with Scedoporium, but one retrospective study in Pittsburgh, PA identified 23 cases of Scedosporium infections (4 in liver, 8 in kidney, 8 in heart, 2 in lung, and 1 in heart-lung transplant) from 1976 and 1999. Recipients of lung transplant were most susceptible, and there was an overall incidence of 1/1000. Another report investigated the cases of Scedosporium infection from 1989 to 2006 at one institution, where all 51 cases were found to involve hematologic malignancy, with 12 cases having bone marrow transplant. In Australia from 1986 and 1999 at another institution, Scedosporium was isolated 9 to 58 months after transplantation for lung or heart-lung transplants. Voriconazole has been utilized to treat Scedosporium, but prognosis is poor for disseminated infections.
Conclusions: Cardiac transplant is improving quality and quantity of life in patients with advanced heart failure, congenital heart disease, coronary artery disease, heart valve disease, cardiomyopathy, and severe arrythmias. One study showed the average life expectancy after transplant to be 9.16 years, crediting the advancements in surgery, immunosuppression drug improvements, and availability of biopsy to diagnose rejection. Of these, immunosuppression has been shown to be a crucial component after cardiac transplant, to reduce cellular rejection. With immunosuppression, there is the caveat of increased risk of infection. Heart transplant patients do not fare well with CNS infection and are a predictor of mortality, even with the more common organisms. In this case, Scedosporium as the causative agent was particularly devastating, due to lack of effective treatments. This fungus, as well as other new and emerging infections in the immunocompromised, are a promising area for new research.