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Infections in dialysis and transplant patients in tropical countries

2000; Elsevier BV; Volume: 57; Linguagem: Inglês

10.1046/j.1523-1755.2000.07415.x

1523-1755

Vivekanand Jha, Sumant S. Chugh, Kirpal S. Chugh,

Pneumocystis jirovecii pneumonia detection and treatment

Infections in dialysis and transplant patients in tropical countries. Infections complicate the course of 50–75% of transplant recipients in the tropical countries, with a mortality of 20–60%. Factors contributing to this dismal outcome include unhygienic conditions, hot and humid climate, late presentation, lack of knowledge about the spectrum of organisms in these areas, scanty diagnostic techniques, and high cost of lifesaving antimicrobial agents. Most of the infections are endemic in these regions. Besides the universally encountered bacterial infections, 7–10% of patients on maintenance dialysis and 10–13% of transplant recipients develop tuberculosis. The prevalence of hepatitis B virus (HBV) varies from 20–45% and that of hepatitis C virus (HCV) from 7–60% in dialysis patients. These figures are significantly higher than their prevalence in the general populations in these regions. The incidence of cytomegalovirus (CMV) disease at autopsy has shown an increase from 4% in the pre-cyclosporine era to 17% after introduction of cyclosporine to the immunosuppressive regimes at our center. Coinfection with other bacterial or fungal organisms is observed more frequently in CMV infected allograft recipients. Clinical and autopsy studies have revealed the incidence of opportunistic fungal infections in allograft recipients between 4–7%, which is likely to be an underestimate. These fungal infections carried a high mortality of over 65% at our center. The protean manifestations with which the opportunistic infections present in immunosuppressed patients and lack of universal availability of sensitive diagnostic tests in underdeveloped countries often delay the diagnosis and institution of therapy. Infections in dialysis and transplant patients in tropical countries. Infections complicate the course of 50–75% of transplant recipients in the tropical countries, with a mortality of 20–60%. Factors contributing to this dismal outcome include unhygienic conditions, hot and humid climate, late presentation, lack of knowledge about the spectrum of organisms in these areas, scanty diagnostic techniques, and high cost of lifesaving antimicrobial agents. Most of the infections are endemic in these regions. Besides the universally encountered bacterial infections, 7–10% of patients on maintenance dialysis and 10–13% of transplant recipients develop tuberculosis. The prevalence of hepatitis B virus (HBV) varies from 20–45% and that of hepatitis C virus (HCV) from 7–60% in dialysis patients. These figures are significantly higher than their prevalence in the general populations in these regions. The incidence of cytomegalovirus (CMV) disease at autopsy has shown an increase from 4% in the pre-cyclosporine era to 17% after introduction of cyclosporine to the immunosuppressive regimes at our center. Coinfection with other bacterial or fungal organisms is observed more frequently in CMV infected allograft recipients. Clinical and autopsy studies have revealed the incidence of opportunistic fungal infections in allograft recipients between 4–7%, which is likely to be an underestimate. These fungal infections carried a high mortality of over 65% at our center. The protean manifestations with which the opportunistic infections present in immunosuppressed patients and lack of universal availability of sensitive diagnostic tests in underdeveloped countries often delay the diagnosis and institution of therapy. Successful kidney transplantation provides the only hope of survival for patients with end-stage renal disease (ESRD) in economically poor countries with inadequate facilities for long-term dialysis1Chugh K.S. Jha V. Differences in the care of ESRD patients worldwide: required resources and future outlook.Kidney Int. 1995; 48: S-7-S-13Google Scholar. In the West, serious infections were noted in about 70% of patients, with a fatal outcome in nearly 40%2Sia I.G. Paya C.V. Infectious complications following renal transplantation.Surg Clin North Am. 1998; 78: 95-112Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar. More recent estimates, however, put the incidence at about 40%. Advances in diagnosis, prevention, and therapy have reduced the mortality to less than 5% in developed countries3Rubin R.H. Infectious disease complications of renal transplantation.Kidney Int. 1993; 44: 221-236Abstract Full Text PDF PubMed Scopus (319) Google Scholar, 4Rubin R.H. Wolfson J.S. Cosimi A.B. et al.Infection in the renal transplant recipient.Am J Med. 1981; 70: 405-412Abstract Full Text PDF PubMed Scopus (291) Google Scholar, 5Kekec Y. Tavli S. Tokyay R. Haberal M.A. Infections after kidney transplantation.Transplant Proc. 1992; 24: 1932-1933PubMed Google Scholar, 6Koyle M.A. Ward H.J. Twomey P.A. Glassock R.J. Rajfer J. Declining incidence of wound infection in cadaveric renal transplant recipient.Urology. 1988; 31: 103-106Abstract Full Text PDF PubMed Scopus (18) Google Scholar, 7Kumar M.S. Cridge P. Molavi A. Stephan R. Abouna G.M. Infectious complications in the first 100 days after renal transplantation.Transplant Proc. 1995; 27: 2705-2706PubMed Google Scholar. In contrast, the lack of transplant registries has prevented a systematic study of the etiology and course of post-transplant infections in tropical countries. Most of the available data are based on the experience of individual physicians from a limited number of centers. It is estimated that infections complicate the course of 50–75% of transplant recipients in tropical countries, with mortality ranging from 20–60%8Morduchowicz G. Pitlik S.D. Shapira Z. Shmueli D. Yussim A. Djalovski S. Rosenfeld J.B. Infections in renal transplant recipients in Israel.Isr J Med Sci. 1985; 21: 791-797PubMed Google Scholar, 9Sidabutar R.P. Sumardjono S. Infection in kidney transplantation recipients in Indonesia.Transplant Proc. 1992; 24: 1934PubMed Google Scholar, 10Gueco I. Saniel M. Mendoza M. Alano F. Ona E. Tropical infections after renal transplantation.Transplant Proc. 1989; 21: 2105-2107PubMed Google Scholar, 11Ramakrishna B. Pillai G. John G.T. Date A. Liver disease in tropical renal transplant patients: an autopsy study.Transplant Proc. 1998; 30: 4325-4326Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 12Chugh K.S. Sakhuja V. Jain S. Talwar P. Minz M. Joshi K. Indudhara R. High mortality in systemic fungal infections following renal transplantation in third-world countries.Nephrol Dial Transplant. 1993; 8: 168-172PubMed Google Scholar, 13Salahudeen A.K. Woods H.F. Pingle A. Nur-El-Huda Suleyman M. Shakuntala K. Nandakumar M. Yahya T.M. Daar A.S. High mortality among recipients of bought living-unrelated donor kidneys.Lancet. 1990; 336: 725-728Abstract PubMed Scopus (94) Google Scholar, 14The Living Non-Related Renal Transplant Study Group Commercially motivated renal transplantation: results in 540 patients transplanted in India.Clin Transplant. 1997; 11: 536-544PubMed Google Scholar, 15Sever M.S. Ecder T. Aydin A.E. Turkmen A. Kilicaslan I. Uysal V. Eraksoy H. Calangu S. Carin M. Eldegez U. Living unrelated (paid) kidney transplantation in third-world countries: high risk of complications besides the ethical problem.Nephrol Dial Transplant. 1994; 9: 350-354PubMed Google Scholar, 16Date A. Vaska K. Vaska P.H. Pandey A.P. Kirubakaran M.G. Shastry J.C. Terminal infections in renal transplant patients in a tropical environment.Nephron. 1992; 32: 253-257Crossref Scopus (22) Google Scholar. The factors contributing to this dismal outcome include unhygienic conditions, hot and humid climate, late presentation, a lack of knowledge about the spectrum of organisms in these areas, and high cost of life-saving antimicrobial agents. Sensitive diagnostic techniques such as tissue biopsy, antigen detection, polymerase chain reaction, and culture facilities for isolating viruses and unusual bacteria and fungi used routinely in the West are either not available or are too expensive. Autopsies are not done, and the cause of death remains unknown in the vast majority of these patients. Since most patients cannot afford long-term maintenance dialysis or a second transplant in the event of graft loss due to rejection, immunosuppressive therapy is often continued even in the face of severe infections, further lowering the immune status and increasing the chances of superinfections with other opportunistic organisms. Although the available general guidelines from experiences in the industrialized nations are valuable in evaluating post-transplant infections, variations in the type and severity of infections in different geographic regions are determined by the epidemiological factors. Infections that are endemic in the general population in tropical regions are expected to occur with increased frequency among renal transplant recipients in these regions. In addition to recent exposure, disease can also result from reactivation of long-dormant focus from a past encounter with the organism, as in the case of Mycobacterium tuberculosis, Strongyloides stercoralis, Leishmania, and certain viruses belonging to the herpes group. A careful history of possible exposure to these organisms in remote past must form part of evaluation of infections in a renal transplant recipient. There have been very few attempts to (i) define the pattern of infections among dialysis and transplant patients in the tropical environment and (ii) to develop specific preventive, diagnostic and therapeutic strategies tailored to the specific organisms encountered in the developing countries. Bacterial infections encountered in patients on maintenance dialysis are generally due to Staphylococcus aureus or gram-negative organisms. Common sites are the respiratory tract and the vascular access sites. Lack of proper hygiene and hot and humid climate promote colonization of vascular access catheters, leading to septicemia and right sided endocarditis. The subject has been reviewed in detail elsewhere17Jha V. Chugh S. Dialysis in developing countries: Priorities and obstacles.Nephrology. 1996; 2: 65-72Crossref Scopus (25) Google Scholar. Among renal transplant recipients, bacterial infections originate most commonly from the urinary tract or the lungs8Morduchowicz G. Pitlik S.D. Shapira Z. Shmueli D. Yussim A. Djalovski S. Rosenfeld J.B. Infections in renal transplant recipients in Israel.Isr J Med Sci. 1985; 21: 791-797PubMed Google Scholar, 18Jha V. Sakhuja V. Gupta D. Sreekrishna V. Chakrabarti A. Joshi K. Sud K. Kohli H.S. Gupta K.L. Successful management of pulmonary tuberculosis in renal allograft recipients in a single center.Kidney Int. 1999; 56: 1944-1950Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 19Wang Z.G. Huang S.F. Renal transplantation with pulmonary infection.Chung Hua Chieh Ho Ho Hu Hsi Tsa Chih. 1993; 16: 24-25Google Scholar. The causative organisms are the same as those prevalent in the general population. The etiologic agent often remains unidentified because of unavailability of isolation techniques, and physicians tend to start broad-spectrum antibiotics on empirical grounds. At our own center, bacterial infections of the lung were observed in 18% of patients in the first year after transplant. All pulmonary infections encountered in the first month were of bacterial origin. Causative organisms could be identified in 50% of the cases and included Pseudomonas aeruginosa, Staphylococcus aureus, and Klebsiella18Jha V. Sakhuja V. Gupta D. Sreekrishna V. Chakrabarti A. Joshi K. Sud K. Kohli H.S. Gupta K.L. Successful management of pulmonary tuberculosis in renal allograft recipients in a single center.Kidney Int. 1999; 56: 1944-1950Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar. As in developed nations, the urinary tract is the most common source of bacterial sepsis following renal transplantation. Serious complications such as emphysematous pyelonephritis in an occasional patient may necessitate graft nephrectomy. Infections with enteric organisms such as Salmonella typhi, S. paratyphi, and Shigella are encountered frequently among the general population in the tropics. There is little evidence that the incidence or course of these infections is altered in transplant recipients. Gueco et al10Gueco I. Saniel M. Mendoza M. Alano F. Ona E. Tropical infections after renal transplantation.Transplant Proc. 1989; 21: 2105-2107PubMed Google Scholar documented Salmonella infection in 5 of their 440 patients. Interestingly, two of them were subjected to nephrectomy in the belief that the graft was acting as a reservoir for the infection. Non-typhoid Salmonella species, such as Campylobacter jejuni and Listeria monocytogenes, are being observed with increasing frequency among renal transplant recipients in western countries3Rubin R.H. Infectious disease complications of renal transplantation.Kidney Int. 1993; 44: 221-236Abstract Full Text PDF PubMed Scopus (319) Google Scholar. Since these infections originate in the gastrointestinal tract, these are expected to occur with a higher frequency in tropical countries where gastrointestinal infections are more common among the general population. No data are available, however, on the prevalence or severity of these infections from the tropical region. Nocardial infections have been documented with a lower frequency among renal transplant recipients in the tropical regions. Similarly, legionella, an important cause of post-transplant pneumonia in the temperate climate, has not been reported. In part, this discrepancy could be accentuated by the lack of awareness and unavailability of specific diagnostic techniques in these regions. Because of its endemicity and the protean ways in which this disease can present, tuberculosis remains a frequent infection among patients on maintenance dialysis and in renal transplant recipients in the tropics. Among dialysis patients, the incidence has been reported to vary between 7–9% in Bangladesh, Indonesia, United Arab Emirates and Saudi Arabia and is more than 10% in India17Jha V. Chugh S. Dialysis in developing countries: Priorities and obstacles.Nephrology. 1996; 2: 65-72Crossref Scopus (25) Google Scholar. Compared to the incidence of less than 1% in the United States and Europe and 4% in the Middle East20Qunibi W.Y. al-Sibai M.B. Taher S. de Harder E.J.E. al-Furayh O. Ginn H.E. Mycobacterial infection after renal transplantation—report of 14 cases and review of the literature.Q J Med. 1990; 77: 1039-1060Crossref PubMed Scopus (152) Google Scholar, this infection is encountered in 10–13% of all renal transplant recipients in the tropical regions21Sakhuja V. Jha V. Varma P.P. Joshi K. Chugh K.S. The high incidence of tuberculosis among renal transplant recipients in India.Transplantation. 1996; 61: 211-215Crossref PubMed Scopus (149) Google Scholar, 22Naqvi A. Aziz T. Hussain M. Zafar N. Muzaffar R. Kazi J. Akhtar F. Ahmad E. Hashmi A. Hussain Z. Rizvi A. Outcome of living-related donor renal allografts in hepatitis C antibody-positive recipients.Transplant Proc. 1998; 30: 793Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 23Hall C.M. Willcox P.A. Swanepoel C.R. Kahn D. Van Zyl Smit R. Mycobacterial infection in renal transplant recipients.Chest. 1994; 106: 435-439Crossref PubMed Scopus (77) Google Scholar, 24Yildiz A. Sever M.S. Turkmen A. Ecder T. Besisik F. Tabak L. Ece T. Kilicarslan I. Ark E. Tuberculosis after renal transplantation: experience of one Turkish centre.Nephrol Dial Transplant. 1998; 13: 1872-1875Crossref PubMed Scopus (68) Google Scholar, 25Malhotra K.K. Dash S.C. Dhawan I.K. Bhuyan U.N. Gupta A. Tuberculosis and renal transplantation—observations from an endemic area of tuberculosis.Postgrad Med J. 1986; 62: 359-362Crossref PubMed Scopus (63) Google Scholar, 26John G.T. Vincent L. Jeyaseelan L. Jacob C.K. Shastry J.C. Cyclosporine immunosuppression and mycobacterial infections.Transplantation. 1994; 58: 247-249Crossref PubMed Google Scholar. We observed tuberculosis in 11.8% of patients at our center. The commonest presentation among transplant recipients in tropics is with pleuropulmonary disease (28–50%) followed by disseminated tuberculosis. About 20–40% patients present with fever of undetermined etiology21Sakhuja V. Jha V. Varma P.P. Joshi K. Chugh K.S. The high incidence of tuberculosis among renal transplant recipients in India.Transplantation. 1996; 61: 211-215Crossref PubMed Scopus (149) Google Scholar. The diagnosis is often made retrospectively after observing a complete response to antitubercular therapy. Less commonly, patients present with isolated involvement of extrapulmonary sites such as skin27Ghosh A.K. Verma P.P. Jha V. Gupta K.L. Sakhuja V. Chugh K.S. Disseminated tuberculosis in a renal transplant recipient presenting as a non-healing skin ulcer. A case report.Int J Artif Organs. 1993; 16: 132-134Google Scholar, bone and joint28Sakhuja V. Varma P.P. Kathuria P. Jha V. Chugh K.S. Bone tuberculosis: an unusual case of mycobacterial infection in a renal allograft recipient.Nephrol Dial Transplant. 1993; 8: 868-870PubMed Google Scholar, gastrointestinal tract20Qunibi W.Y. al-Sibai M.B. Taher S. de Harder E.J.E. al-Furayh O. Ginn H.E. Mycobacterial infection after renal transplantation—report of 14 cases and review of the literature.Q J Med. 1990; 77: 1039-1060Crossref PubMed Scopus (152) Google Scholar,21Sakhuja V. Jha V. Varma P.P. Joshi K. Chugh K.S. The high incidence of tuberculosis among renal transplant recipients in India.Transplantation. 1996; 61: 211-215Crossref PubMed Scopus (149) Google Scholar, larynx29Jha V. Kohli H.S. Sud K. Gupta K.L. Minz M. Joshi K. Sakhuja V. Laryngeal tuberculosis in renal transplant recipients.Kidney Int. 1999; 56: 1944-1950Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, renal allograft21Sakhuja V. Jha V. Varma P.P. Joshi K. Chugh K.S. The high incidence of tuberculosis among renal transplant recipients in India.Transplantation. 1996; 61: 211-215Crossref PubMed Scopus (149) Google Scholar,30Mansour A.M. Renal allograft tuberculosis.Tubercle. 1990; 71: 147-148Abstract Full Text PDF PubMed Scopus (12) Google Scholar and pericardium25Malhotra K.K. Dash S.C. Dhawan I.K. Bhuyan U.N. Gupta A. Tuberculosis and renal transplantation—observations from an endemic area of tuberculosis.Postgrad Med J. 1986; 62: 359-362Crossref PubMed Scopus (63) Google Scholar. Cutaneous tuberculosis may present with a nonhealing skin ulcer, and the diagnosis is made by demonstrating acid-fast bacilli (AFB) on smears from the ulcer bed or on histology. Patients with laryngeal tuberculosis present with a long history of hoarseness of voice and/or odynophagia. The latter symptom is considered pathognomonic of tubercular involvement of the larynx. Laryngoscopy shows granulation tissue on the vocal cords. Laryngeal carcinoma is a close differential diagnosis, and histology usually clinches the diagnosis. Diagnosis of tubercular osteomyelitis requires a high index of suspicion. Mycobacterial involvement of bone has to be present for over 6 weeks before radiological changes become evident31Tuli S.M. Brighton C.T. Morton H.E. Clark L.W. The experimental induction of localized skeletal tuberculosis lesions and their accessibility to streptomycin.J Bone Joint Surg. 1974; 56: 551-559Google Scholar. Involvement of renal allograft is usually seen as part of disseminated disease, and should be suspected in patients who show focal lesions in the allograft on ultrasonography and/or CT scan. The diagnosis can be confirmed by demonstrating AFB on fine needle aspiration from the lesion. Although M. tuberculosis is the most common species isolated from these patients, infection with atypical Mycobacteria such as M. kansasii, M. marinum, M. avium-intracellulare and M. fortuitum has also been documented20Qunibi W.Y. al-Sibai M.B. Taher S. de Harder E.J.E. al-Furayh O. Ginn H.E. Mycobacterial infection after renal transplantation—report of 14 cases and review of the literature.Q J Med. 1990; 77: 1039-1060Crossref PubMed Scopus (152) Google Scholar. Since these organisms are much less sensitive than M. tuberculosis to the conventional antitubercular agents, the species identification by culturing the specimen on appropriate media assumes considerable importance. Tuberculosis presents numerous diagnostic difficulties in renal transplant recipients. Because of the high frequency of cutaneous anergy in immunosuppressed patients, the Mantoux test is generally unhelpful as a diagnostic tool. The classic picture of apical involvement on chest X ray is seen in only a minority of renal transplant recipients with pulmonary tuberculosis18Jha V. Sakhuja V. Gupta D. Sreekrishna V. Chakrabarti A. Joshi K. Sud K. Kohli H.S. Gupta K.L. Successful management of pulmonary tuberculosis in renal allograft recipients in a single center.Kidney Int. 1999; 56: 1944-1950Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar. Demonstration of AFB in the sputum smear requires repeated examination on several occasions and has a low yield. Identification on culture takes 4–6 weeks. For these reasons, the diagnosis is often delayed, during which time the disease continues to spread. Recently, bronchoalveolar lavage (BAL) has been shown to be useful in making an early and accurate diagnosis of tuberculosis in renal transplant recipients. AFB could be identified by BAL in 88% patients with pulmonary tuberculosis18Jha V. Sakhuja V. Gupta D. Sreekrishna V. Chakrabarti A. Joshi K. Sud K. Kohli H.S. Gupta K.L. Successful management of pulmonary tuberculosis in renal allograft recipients in a single center.Kidney Int. 1999; 56: 1944-1950Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar. Bronchoscopy and BAL should, therefore, be performed early in patients with unexplained pulmonary infiltrates in endemic areas. Treatment of post-transplant tuberculosis presents problems both in the choice of antitubercular agents and duration of therapy. Rifampicin is a well known hepatic P-450 microsomal enzyme inducer, increasing the clearance of both prednisolone and cyclosporine A. There are no data on glucocorticoid pharmacokinetics in patients on steroids, and it is a common practice to double the prednisolone dose. The dose of prednisolone needs to be doubled and that of cyclosporine increased to almost 3–4 fold to maintain therapeutic blood levels. The latter increases the cost of therapy and is unacceptable to a vast majority of patients. An alternative regime that has been successfully used for these patients consists of a combination of isoniazid (INH), pyrazinamide, ciprofloxacin and ethambutol21Sakhuja V. Jha V. Varma P.P. Joshi K. Chugh K.S. The high incidence of tuberculosis among renal transplant recipients in India.Transplantation. 1996; 61: 211-215Crossref PubMed Scopus (149) Google Scholar. The optimum duration of therapy is also a matter of debate. Riska et al32Riska H. Gronhagen-Riska C. Ahonen J. Tuberculosis and renal allograft transplantation.Transplant Proc. 1987; 19: 4096-4097PubMed Google Scholar recommend treatment of these patients for 9 months. This therapy may be appropriate for patients with pulmonary tuberculosis who are on both INH and rifampicin, but most centers extend the treatment to 12 months. The duration needs to be increased to 18 months in patients who are on cyclosporine and are not receiving rifampicin. The role of INH prophylaxis after transplant is controversial. In one study carried out in a low-endemicity area, tuberculosis was seen in 22% of high-risk patients, but all patients who had received INH prophylaxis were protected20Qunibi W.Y. al-Sibai M.B. Taher S. de Harder E.J.E. al-Furayh O. Ginn H.E. Mycobacterial infection after renal transplantation—report of 14 cases and review of the literature.Q J Med. 1990; 77: 1039-1060Crossref PubMed Scopus (152) Google Scholar. In contrast, in a study of 184 Indian patients, John et al33John G.T. Thomas P.P. Thomas M. Jeyaseelan L. Jacob C.K. Shastry J.C. A double-blind randomized controlled trial of primary isoniazid prophylaxis in dialysis and transplant patients.Transplantation. 1994; 57: 1683-1684Crossref PubMed Scopus (84) Google Scholar did not find any reduction in the incidence of this disease in those who received INH prophylaxis. On the other hand, INH had to be discontinued in a significant proportion of patients because of development of hepatitis. Another important concern is the development of drug-resistant tuberculosis. The incidence of primary INH resistance is increasing steadily34John G.T. Mukundan U. Vincent L. Jacob C.K. Shastry J.C. Primary drug resistance to Mycobacterium tuberculosis in renal transplant recipients.Natl Med J India. 1995; 8: 211-212PubMed Google Scholar. Prophylaxis with INH is therefore not only likely to be ineffective, but has the potential of increasing emergence of resistant bacilli. The American Thoracic Society recommends prophylactic INH administration to Mantoux-positive patients35Dautzenberg B. Grosset J. Fechner J. Lucciani J. Debre P. Herson S. Truffot C. Sors C. The management of thirty immunocompromised patients with tuberculosis.Am Rev Respir Dis. 1984; 129: 494-496PubMed Google Scholar. This strategy, however, is unlikely to be applicable in endemic areas, both because of a high degree of Mantoux positivity in the general population36Park J.E. Park K. Textbook of Preventive and Social Medicine. Banarasidas Bhanot, Jabalpur1985Google Scholar as well as the high frequency of false-negative tests among chronic renal failure (CRF) patients. Routine INH prophylaxis is therefore not recommended in endemic areas. Fungal infections encountered among renal transplant recipients are either localized mucocutaneous or systemic infections. Mucocutaneous fungal infections are documented in 60–72% of all renal allograft recipients in the tropical countries37Chugh K.S. Sharma S.C. Singh V. Sakhuja V. Jha V. Gupta K.L. Spectrum of dermatological lesions in renal allograft recipients in a tropical environment.Dermatology. 1994; 188: 108-112Crossref PubMed Scopus (47) Google Scholar,38Vijayakumar R. Fernando E. Rajendran S. Jayakumar M. Muthusethupathi M.A. Dermatological manifestations in renal transplant recipients.Transplant Proc. 1998; 30: 3136Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar. The common organisms responsible for these infections include Tinea corporis, T. cutis and T. versicolor (55–65%), followed by Candida (7–9%) and Cryptococcus (0–1%). The hot and humid climate, poor hygiene, and frequent use of broad-spectrum antibiotics increase the risk of colonization and local spread of these fungi. Oro-esophageal candidiasis is noted in about 10% of all renal transplant recipients39Gupta K.L. Ghosh A.K. Kochhar R. Jha V. Chakrabarti A. Sakhuja V. Esophageal candidiasis after renal transplantation: comparative study in patients on different immunosuppressive protocols.Am J Gastroenterol. 1994; 89: 1062-1065PubMed Google Scholar. The incidence is higher in those on triple immunosuppressive therapy compared to those taking only azathioprine and prednisolone. In over 50% of patients, the involvement is limited to the esophagus. The usual presenting feature is dysphagia and, less commonly, gastrointestinal bleeding. Topical therapy is usually effective in controlling mucocutaneous fungal infections37Chugh K.S. Sharma S.C. Singh V. Sakhuja V. Jha V. Gupta K.L. Spectrum of dermatological lesions in renal allograft recipients in a tropical environment.Dermatology. 1994; 188: 108-112Crossref PubMed Scopus (47) Google Scholar. The drugs used include azoles or terbinafine for cutaneous infections and nystatin or clotrimazole for oro-esophageal candidiasis. Prolonged oral therapy with griseofulvin or fluconazole is necessary in patients with extensive cutaneous disease or involvement of nails. The leukocyte count should be monitored regularly during griseofulvin therapy to prevent life-threatening granulocytopenia. A short course of oral fluconazole is effective for esophageal candidiasis that does not resolve with local therapy39Gupta K.L. Ghosh A.K. Kochhar R. Jha V. Chakrabarti A. Sakhuja V. Esophageal candidiasis after renal transplantation: comparative study in patients on different immunosuppressive protocols.Am J Gastroenterol. 1994; 89: 1062-1065PubMed Google Scholar. Systemic fungal infections are divided into two classes: those due to opportunistic organisms such as Candida, Aspergillus, Cryptococcus or Mucor and geographically restricted mycoses, caused by histoplasma, coccidioides, blastomycetes. Clinical and autopsy studies put the incidence of fungal infections among renal transplant recipients in the tropical countries at 4–7%12Chugh K.S. Sakhuja V. Jain S. Talwar P. Minz M. Joshi K. Indudhara R. High mortality in systemic fungal infections following renal transplantation in third-world countries.Nephrol Dial Transplant. 1993; 8: 168-172PubMed Google Scholar, 44John G.T. Mathew M. Snehalatha E. Anandi V. Date A. Jacob C.K. Shastry J.C. Cryptococcosis in renal allograft recipients.Transplantation. 1994; 58: 855-856Crossref PubMed Scopus (45) Google Scholar, 45Agarwal A. Gupta A. Sakhuja V. Talwar P. Joshi K. Chugh K.S. Retinitis following disseminated cryptococcosis in a renal allograft recipient. Efficacy of oral fluconazole.Acta Ophthalmol (Copenh). 1991; 69: 402-405Crossref Scopus (15) Google Scholar. This figure is likely to be an underestimate as the infections remain undiagnosed in patients who do not come for follow up or are reported to have died and autopsy was not done. Nampoory et al41Nampoory M.R. Khan Z.U. Johny K.V. Constandi J.N. Gupta R.K. Al-Muzairi I. Samhan M. Mozavi M. Chugh T.D. Invasive fungal infections in renal transplant recipients.J Infect. 1996; 33: 95-101Abstract Full Text PDF PubMed Scopus (99) Google Scholar noted a high incidenc