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Altered mental status is common in the solid organ transplant recipient. A variety of etiologies, including infections, metabolic abnormalities, medications, malignancies, and rejection, can lead to altered mental status in a transplant patient. Timeline after transplantation as well as organ transplanted have significant impact on etiology. Detailed physical examination, comprehensive laboratory evaluation, and in many cases imaging can help elucidate the etiology. Urgent treatment of underlying etiology can improve prognosis.

Solid organ and hematopoietic stem cell transplant recipients are at high risk of contracting infectious diseases, including vaccine-preventable illnesses, in the post-transplant period. Given the high degree of immunosuppression immediately post-transplant, infection in the transplant patient results in higher morbidity and mortality than in the general population. Thus, it is the responsibility of the care team to ensure appropriate vaccines are given in an attempt to mitigate this risk....

This chapter is a review of rare yet clinically relevant viral encephalitides that have been transmitted from organ donors to recipients. We will discuss the potential pitfalls in diagnosing and managing these illnesses and also discuss the challenges and next steps to better outcomes from these infections.

Hepatitis B virus (HBV) and hepatitis D virus (HDV) are hepatotropic viruses that can have a significant impact on patients undergoing solid organ and hematopoietic stem cell transplants. In the setting of transplant immunosuppression, patients with HBV or HDV coinfection can have acceleration in the natural history of their liver diseases with increased risk of developing cirrhosis, decompensation, and hepatocellular carcinoma. Immunosuppression can also reactivate HBV in patients with...

Cytomegalovirus (CMV) is among the most common of infections after transplant. In addition to causing viral infection, it increases the risk for a negative outcome for the organ or bone marrow graft, as well as for higher overall morbidity and mortality. Risk of CMV is especially high in transplant recipients previously nonimmune to the virus. Prevention is key for optimal outcomes, both for individuals and for transplant programs. Optimal disease recognition, diagnostics, prevention, and...

Infections are an important cause of morbidity and mortality after transplantation. Some of these infections are environmental and geographically or seasonally important. West Nile virus is one such infection, tied to the epidemiology of infected mosquitos which varies over time. It can cause disease for a transplant recipient either from direct inoculation from an infected mosquito or as a donorderived infection. This chapter reviews current data about the epidemiology of West Nile virus,...

Antimicrobial stewardship is an essential component of transplant programs to improve patient outcomes, reduce the threat of antimicrobial resistance, and lower the risk of drug toxicity. A multidisciplinary approach that leverages the existing team-based infrastructure of transplant programs and encompasses partnership with pharmacy, infection prevention, and microbiology is important for successful implementation. This chapter outlines the importance of stewardship in transplantation,...

Infections due to adenoviruses confer significant morbidity and mortality in immunocompromised hosts. Manifestations of disease in the setting of hematopoietic stem cell and solid organ transplantation may range from asymptomatic shedding or viremia to localized infection and disseminated disease. In solid organ transplant recipients, adenoviral disease often involves the allograft and can lead to graft dysfunction and/or graft loss. Several diagnostic methods are available for adenovirus...

The hepatitis E virus (HEV) is one of the main causative agents of acute viral hepatitis worldwide. Over the past decade, HEV genotypes 3 and 4 have been responsible for chronic infections in immunocompromised patients, especially solid organ transplant recipients. A rapid progression of liver fibrosis and the development of HEV-related cirrhosis have been documented in this specific population. HEV infections have also been associated with extrahepatic manifestations such as neurological...

Cases of malaria infection have been reported in solid organ and hematopoietic stem cell transplantation; malaria infections may occur as a consequence of a donor-derived infection (from organ or blood), as a relapse of previous P. vivax or P. ovale infection, or as newly acquired infections after transplantation in endemic areas. In donors or candidates with epidemiological risk of malaria infection, sensitive techniques in laboratory surveillance, including molecular tests, to rule out...

Cytopenias are a common occurrence in both hematopoietic stem cell and solid organ transplant recipients, particularly in the early post-transplant time period. The etiology is frequently multifactorial, reflecting the simultaneous interplay of infection, immunologic derangements, and medication effects in this patient population. These factors continually change over time, further adding to the complexity of diagnosis and management. Thorough evaluation of the individual’s medical history,...

Cystic fibrosis is an autosomal recessive inherited disorder of salt transport. The natural history of the disease is determined by the development of chronic bronchiectasis and ensuing chronic colonization with multidrug-resistant bacteria and fungi. End-stage lung disease commonly necessitates lung transplant, and occasionally even combined lung/liver or lung/kidney transplant may be the only way forward for affected patients. Due to the common organisms colonizing the lungs of patients...

Infectious complications are a major cause of morbidity and mortality in both solid organ and hematopoietic stem cell transplant patients. The risk of infection by common opportunistic pathogens like cytomegalovirus can be mitigated with the optimal use of molecular diagnostics and antiviral prophylaxis. Novel and emerging bacterial, viral, fungal, and parasitic pathogens may be more successfully managed with early diagnosis and therapy. In the care of solid organ and hematopoietic stem cell...

While some biologicals have been routinely used in solid organ and hematopoietic stem cell transplant patients for years, a number of newer compounds have been added to the armamentarium for varying indications spanning from the underlying disease to complications of transplantation. This chapter aims at describing the infectious risk of a selection of compounds. The specific chapters list a number of recommendations to consider for infection prevention, in addition to the standard...

Transplantation in recent years has become a viable option to treat end stage organ failure in people living with HIV infection. Significant advances in the understanding of appropriate immunosuppression management and infection prevention have resulted in graft and patient survival comparable to HIV-negative recipients in many cases. Given the higher incidence of end stage organ disease in HIV positive patients, particularly liver cirrhosis and dialysis dependent renal failure, transplant...

Characteristics of transplant candidates can significantly impact risk for infection after transplantation and immunosuppression start. These characteristics include a wide variety of risk factors for potential infection ranging from country of origin and travel history to history of immunosuppression, to certain comorbid conditions, and to diet and occupation. Increased mobility and medical complexity of transplant patients, and the changing epidemiology of pathogen distribution, can...

Influenza virus is a common respiratory virus in solid organ and stem cell transplant recipients. Influenza infection in immunocompromised hosts can result in severe disease, as compared to general population. Risk factors for severe influenza infection in transplant recipients include treatment with antilymphocyte globulin, presence of lower respiratory disease, and infection early after transplantation. Transplant programs should act to optimize prevention, early diagnosis, and treatment of...

The endemic fungi are a group of thermally dimorphic fungi that occupy specific defined environmental ranges. They count Histoplasma, Blastomyces, Paracoccidioides, Coccidioides, Talaromyces, Emergomyces, and Sporothrix among their number. In the environment, they exist as molds, and at body temperature, they transform into their pathogenic yeast form (or, in the case of coccidioidomycosis, into a specialized structure called a spherule). Histoplasma, Blastomyces, and Paracoccidioides are...

Multidrug-resistant organisms (MDROs) cause morbidity and mortality after organ transplantation. Infection from these organisms may arise from pre-transplant colonization/infectious events, and these organisms may be donor-derived. Here we review the epidemiology, clinical manifestations, disease diagnostics, and therapeutic modalities for six common MDRO bacterial pathogens in the context of solid organ and bone marrow transplantation.

Coccidioidomycosis is an infection due to the fungal species Coccidioides, which is most heavily endemic in the desert southwestern USA. Although early studies of this infection among transplant recipients in the endemic region were complicated by high morbidity and mortality, solid organ and hematologic stem cell transplantation can be a successful undertaking within the Coccidioides-endemic region. Such success has been attributed to careful attention to screening for and treatment of...