Coccidioidomycosis in Renal Transplant Recipients

Coccidioidomycosis is endemic in the southwest United States, and impaired cellular immunity profoundly increases the susceptibility to life-threatening Coccidioides immitis infections. This study combines the clinical presentation of coccidioidomycosis in 5 renal transplant recipients in El Paso from 1987 to 2002 with details from 28 other cases published in the literature from 1966 to 2002. The 5 cases in El Paso occurred in a population of 297 transplant recipients. Overall, the 33 renal transplant recipients with coccidioidomycosis included 24 men and 9 women with a median age of 38 years. Fifty-eight percent of the patients were white, 33% Hispanic, 3% African American, 3% Native American, and 3% Asian. Twenty-three (70%) of the patients had cadaveric donors, and the remainder had living donors. Underlying renal diseases included chronic glomerulonephritis (48%), diabetes mellitus (30%), autoimmune diseases (3%), Alport syndrome (3%), and others not documented (16%). C. immitis was isolated from the lung in 75% of the patients; in the remaining 25%, it involved the spleen, urine, skin, pancreas, bone marrow, thyroid, choroid, and lymph nodes. In the majority of the patients, the initial clinical presentation included fever with clinical and radiographic evidence of pneumonia. The median time between transplantation and the diagnosis of infection was 6 months (15 days to 50 months). Disseminated coccidioidomycosis occurred in 18 patients. Treatment modalities included amphotericin B in 29 patients (88%) and fluconazole in 6 patients (18%). Death occurred in 55% (18) of the patients with 9 of them dying from coccidioidomycosis and the other 9 dying of other causes. There did not appear to be a significant increase in the mortality in patients who had underlying diabetes mellitus.