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Background: Lung transplant recipients are at high risk for severe cytomegalovirus (CMV) disease. Off‐label use of letermovir (LET) may avert myelotoxicity associated with valganciclovir (VGCV), but data in lung transplantation are limited. This study aims to evaluate the outcomes of LET prophylaxis among lung transplant recipients. Methods: This retrospective, matched cohort study included lung transplant recipients who received LET for primary CMV prophylaxis following VGCV intolerance. Patients were matched 1:1 to historical VGCV controls based on age, serostatus group, and time from transplant. The primary outcome was CMV breakthrough within 1 year post‐LET initiation; secondary outcomes included hematologic changes. Results: A total of 124 lung transplant recipients were included per group (32% CMV mismatch, D+R‐), with LET initiated a median of 9.6 months post‐transplantation. One CMV breakthrough event (0.8%) was observed in the LET group versus four (3.2%) in the VGCV group (p =.370). The median (interquartile range) white blood cell (WBC) count was 3.1 (2.1–5.6) at LET initiation which increased to 5.1 (3.9–7.2) at the end of follow‐up (p <.001). For VGCV controls, WBC was 4.8 (3.4–7.2) at baseline and 5.4 (3.6–7.2) at the end of follow‐up; this difference was not statistically significant (p =.395). Additionally, 98.4% of LET patients experienced ≥1 leukopenia episode in the year prior to LET compared to 71.8% the year after initiation (p <.001). Similar results were observed for neutropenia (48.4% and 17.7%, p <.001). Conclusion: LET prophylaxis was associated with a low rate of CMV reactivation and leukopenia recovery. LET may represent a reasonable prophylaxis option for lung transplant recipients unable to tolerate VGCV. [ABSTRACT FROM AUTHOR]

Background: In the general population, prior infection with SARS‐CoV‐2 reduces the risk of severe COVID‐19; however, studies in lung transplant recipients (LTRs) are lacking. We sought to describe the clinical course of COVID‐19 recurrence and compare outcomes between the first and second episodes of COVID‐19 in LTRs. Methods: We conducted a retrospective, single‐center cohort study of LTRs with COVID‐19 between January 1, 2022, and September 30, 2022, during the Omicron wave. We compared the clinical course of a second episode of COVID‐19 to that of the patients' own first episode and to that of LTRs who developed a first episode during the study period. Results: During the study period, we identified 24 LTRs with COVID‐19 recurrence and another 75 LTRs with a first episode of COVID‐19. LTRs who survived the initial episode of COVID‐19 had a similar disease course with recurrence, with a trend toward reduced hospitalization (10 (41.6%) vs. 4 (16.7%), p =.114). Furthermore, compared to LTRs with a primary infection during the Omicron wave, those with a reinfection had a non‐statistically significant trend toward reduced hospitalizations (aOR.391, 95% CI [.115–1.321], p =.131), shorter lengths‐of‐stay (median, 4 vs. 9 days, p =.181), and reduced intensive care unit admissions, intubations, and COVID‐19–related mortality. Conclusions: LTRs who survive the first episode of COVID‐19 are likely to have a similar clinical course with recurrent episodes. Although recurrent COVID‐19 may be milder, larger, well‐powered studies are needed to confirm this observation. Ongoing precautions are warranted. [ABSTRACT FROM AUTHOR]

TEM and immunostaining of the exosomes using Abs specific to SARS-CoV-2 spike protein S2 and nucleocapsid protein revealed the presence of the spike protein S2 and nucleocapsid antigen on the surface of exosomes (Figure 3A). SARS-CoV-2 spike protein S2 in the exosomes also suggests that the exosomes acquire the spike protein antigen during active infection. SARS-CoV-2 infection in lung transplant recipients induces circulating exosomes with SARS-CoV-2 spike protein S2. [Extracted from the article]

Background: Lung transplant recipients are at heightened risk for nocardiosis compared to other solid organ transplant recipients, with incidence rates as high as 9% and up to 30% associated mortality. No controlled studies assessing risk factors for nocardiosis in this high‐risk population have been reported. Methods: Patients undergoing lung transplantation at a single center between 2012 and 2018 and diagnosed with nocardiosis post‐transplant were matched 1:2 to uninfected control subjects on the basis of age, transplant date, and sex. Results: The incidence of nocardiosis in this lung transplant population was 3.4% (20/586), occurring a median of 9.4 months (range 4.4‐55.2) post‐transplant. In multivariable analysis, consistent use of trimethoprim/sulfamethoxazole (TMP/SMX) in the 12 weeks prior to diagnosis was independently associated with protection against nocardiosis (OR 0.038; 95% CI 0.01‐0.29; P =.002). Augmented immunosuppression in the 6 months prior to diagnosis was independently associated with the development of nocardiosis (OR 9.94; 95% CI 1.62‐ 61.00; P =.013). Six case patients (30%) had disseminated disease; all‐cause 6‐month mortality was 25%. The most common species was Nocardia farcinica (7/17 isolates), which was associated with dissemination and mortality. The most active antibiotics were TMP/SMX (100%), linezolid (100%), and amikacin (76%). Imipenem was only active against 4/17 isolates (24% susceptibility), with two isolates becoming non‐susceptible later in therapy. Conclusions: Trimethoprim/sulfamethoxazole prophylaxis was shown to be protective against nocardiosis in lung transplant recipients, while augmented immunosuppression conferred increased risk. Institutional epidemiologic data are needed to best guide empiric therapy for Nocardia, as historical in vitro data may not predict local susceptibilities. [ABSTRACT FROM AUTHOR]

Exosomes isolated from plasma of lung transplant recipients with allograft injury contain donor‐derived lung self‐antigens (collagen V and Kα1 tubulin) and human leukocyte antigen (HLA) molecules. We present a case of a 76‐year‐old, female lung transplant recipient treated for acute cellular rejection with methylprednisolone and anti‐thymocyte globulin, who subsequently contracted SARS‐CoV‐2 and developed a sharp increase in the mean fluorescent intensity of anti‐HLA antibodies. Analysis of circulating exosomes during rejection, but before SARS‐CoV‐2 infection, revealed the presence of lung self‐antigens and HLA class II molecules. After the patient contracted SARS‐CoV‐2, exosomes with the SARS‐CoV‐2 spike protein were also found. After resolution of infectious symptoms, exosomes with SARS‐CoV‐2 spike protein were no longer detected; however, exosomes with lung self‐antigens and HLA class II molecules persisted, which coincided with a progressive decline in spirometric flows, suggesting chronic lung allograft dysfunction. We propose that the analysis of circulating exosomes may be used to detect allograft injury mediated by both rejection and infection. Furthermore, the detection of exosomes containing viral proteins may be helpful in identifying allograft injury driven by viral pathogens. [ABSTRACT FROM AUTHOR]

Background and objective In low and middle-income countries where HIV infection is prevalent, identifying patients at high risk of dying from lower respiratory tract infections is challenging and validated prognostic models are lacking. Serum procalcitonin may be a useful prognostic tool in these settings. We sought to determine if elevated serum procalcitonin is associated with increased in-hospital mortality and to combine serum procalcitonin with available clinical characteristics to create a clinically useful prognostic model. Methods We conducted a prospective, nested case-control study of 241 HIV-infected adults admitted to Mulago Hospital in Kampala, Uganda with cough ≥2 weeks in duration. We collected demographic and clinical information, baseline serum for procalcitonin analysis, and followed patients to determine in-hospital mortality. Results Serum procalcitonin was a strong and independent predictor of inpatient mortality ( aOR = 7.69, p = 0.01, sensitivity = 93%, negative predictive value = 97%). Best subset multivariate analysis identified 3 variables that were combined into a prognostic model to risk stratify patients; these variables included respiratory rate ≥30 breaths/minute ( aOR = 2.07, p = 0.11), oxygen saturation <90% ( aOR = 3.07, p = 0.02), and serum procalcitonin >0.5 ng/ml ( aOR = 7.69, p = 0.01). The predicted probability of inpatient mortality ranged from 1% when no variables were present, to 42% when all variables were present. Conclusions Elevated serum procalcitonin >0.5 ng/ml is an independent predictor of in-hospital mortality. Elevated serum procalcitonin, tachypnea, and hypoxemia may be combined into a prognostic model to identify patients at high risk of dying in the hospital. This model may be used to estimate the probability of death and to guide triage and treatment decisions. [ABSTRACT FROM AUTHOR]