© 2009 American Thoracic Society
Death after Lung Transplantation in Cystic Fibrosis Patients Infected with Burkholderia cepaciaTo the Editor:We read with interest the article by Dr. Murray and colleagues (1), which examined the post–lung transplantation outcomes of patients with cystic fibrosis and Burkholderia cepacia complex infection. Excess mortality was largely seen in patients with B. cenocepacia infection, and infection with species other than B. cenocepacia was not associated with worse outcomes (1). These data support recent reports from other groups (2, 3). We have had recent experience of early mortality in two patients with cystic fibrosis following lung transplant with chronic B. cepacia (genomovar I) infection. A 44-year-old female died 9 weeks post-transplant from overwhelming pulmonary infection. The early postoperative clinical course was excellent, including discharge from the hospital on Day 24 and no episodes of augmented immunosuppression. A male, 23 years of age, succumbed to progressive pulmonary infection 8 weeks post-transplant following the acquisition of an Influenza A and RSV coinfection on Day 53. The early postoperative clinical course was excellent, including discharge from hospital on Day 19. Treatment of the viral infection included ribavirin and pulse methylprednisolone therapy. Influenza vaccine had been administered pretransplant, but the antigenic component of the vaccine did not match the strain isolated from the patient. Bronchoscopy washing and blood cultures revealed B. cepacia. These deaths occurred despite the use of routine protocols for patients with B. cepacia complex infection aimed at reducing risk of sepsis, including IL-2 receptor blocker monoclonal antibodies, cyclosporine targeting low therapeutic levels, intravenous antibiotics based on multiple combination bactericidal testing, and avoidance of surveillance transbronchial biopsies. Kidd and colleagues (4) found that the proportion of Australian patients with cystic fibrosis and B. cepacia infection (previously known as genomovar I) is higher (11.2%) than most previous reports. Whereas early septic complications following lung transplantation have not been seen in our patients with B. cenocepacia, it has occurred in two patients with B. cepacia infection. The identification of a concurrent viral infection in one case could suggest a potential "priming" effect, which may have influenced the pathogenicity of B. cepacia infection. In each case, molecular typing demonstrated retention of the same B. cepacia strain after transplantation, but strains from each patient were unrelated. Despite antibiotic treatment based on available multiple combination bactericidal testing of B. cepacia (5), control of infection was not achievable. These cases exemplify the potential for "cepacia syndrome" post-transplant due to B. cepacia in patients with cystic fibrosis, adding to concerns about post-transplant outcomes in patients with B. cenocepacia and B. gladioli (1–3).
The Prince Charles Hospital
University of Queensland
Pathology Queensland
Gold Coast Hospital
Pathology Queensland
University of Queensland FOOTNOTES Conflict of Interest Statement: P.M.H. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. T.J.K. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. C.C. served on a scientific advisory board for Wyeth Australia in 2005 and 2006, receiving AUD 1000; he received AUD 575 for chairing a meeting on behalf of Wyeth Australia in 2006; he was principal investigator for a laboratory research study which was supported by an unrestricted educational grant of $9,000 from Merck Sharp & Dohme (Australia). I.H.F. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. P.D. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. S.C.B. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. REFERENCES
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