Infection and Malignancy

Preventing Infection and Cancer After an Organ Transplant

As a transplant recipient, you have a higher risk of developing infection and certain types of cancer because you are taking anti-rejection medications. These anti-rejection drugs keep the immune system from attacking your new organ. However, they also weaken your body’s natural ability to attack organisms of all types that enter the body.
All infections in transplant recipients with a weakened immune system should be considered serious, though most are not life-threatening. Taking steps to avoid infection is important to your health. Also, recognizing the signs of infection and taking immediate action can help stop these organisms from making you sick.

Infections From A Hospital Stay

Infections after surgery and other hospital procedures are a significant problem in transplant patients. . The use of catheters and intravenous lines to deliver medication carries some risk for infection. Some patients may develop pneumonia shortly after surgery. Common signs of infection from a hospital stay include:

Fever and chills
Redness or unusual pain around the incision
Fluid leaking from the incision
New cough with sputum production
Pain when urinating
Pain or redness where the catheter was inserted
Diarrhea or abdominal pain, nausea, and vomiting
Headache that lasts a long time

If you think you have an infection, be sure to tell your doctor immediately.

Infection After Returning Home

Transplant recipients are more likely to get an infection from different types of organisms after they return home from the hospital.

Viral Infections

There are several forms of viral infections that transplant recipients can get after returning home from the transplant center.

Herpes simplex virus (HSV). This virus can remain hidden in your body for years, but can become active again due to stress, illness, or immune suppression. HSV causes cold sores in the mouth or skin ulcers.
Shingles. Shingles are caused by varicella zoster virus (VZV), another type of herpes virus that causes chicken pox. The virus remains in the body in nerves and can be activated by immune suppression with anti-rejection drugs.
Cytomegalovirus (CMV). CMV is also a type of herpes virus and can remain hidden and become active again. Once activated, CMV may cause fever, low white blood cell count, muscle aches, diarrhea, or occasionally infection of organs.
Epstein-Barr virus (EBV). EBV causes infectious mononucleosis. EBV is also associated with cancer — called post-transplant lymphoproliferative disorder (PTLD) — of certain white blood cells.
BK polyomavirus. The BK polyomavirus infects the kidney causing damage to a kidney transplant.
Papillomavirus. Some transplant recipients develop warts caused by papillomavirus. This family of viruses is also implicated in cervical cancers and some skin cancers

Hepatitis B virus (HBV). Hepatitis B is a viral infection of the liver. In most patients, hepatitis B resolves over time. However, in others it may progress and cause permanent liver damage (cirrhosis). HBV infection and cirrhosis increase the risk for developing liver cancer.
Hepatitis C virus (HCV). Hepatitis C is also a viral infection of the liver. It causes liver inflammation and can lead to permanent injury (cirrhosis). Cirrhosis due to HCV infection is associated with an increased risk for developing liver cancer.
Influenza and respiratory viruses. Influenza (the "flu") is a viral infection of the nose and throat.
Respiratory syncytial virus (RSV). RSV starts as an upper respiratory tract infection but may also cause pneumonia. It is more common in children than adults.
West Nile virus (WNV) and Eastern equine encephalitis virus (EEEV). These viruses are spread by mosquitoes. You should protect yourself against mosquito bites by using and wearing long-sleeved shirts and pants when outdoors.

Some viruses can go into hiding (latency) only to become active again. New and hidden viral infections can be diagnosed by a blood test. You will also need to be on the lookout for the signs and symptoms of viral infections.

Figure. Viral Infections

Medications are available to help treat or prevent many illnesses caused by viruses. You may need to take them for several months or longer.

Bacterial Infections

When the immune system is changed by transplant medications or surgery, the risk for bacterial infections goes up. Bacterial infection may cause fever and chills, diarrhea, cough, headache, shortness of breath, pain when urinating, abdominal pain, nausea, vomiting, a new rash, or other signs. Infections are easiest to treat when caught early, so it is important to call your transplant team immediately if you think you might have an infection.

Fungal Infections

In some transplant recipients, organisms called fungi (such as molds or yeasts) may cause infection. Fungi called Candida can produce a whitish coating in the mouth and throat ("thrush"). This type of fungal infection is easily treated. Others fungi may cause pneumonia or other serious infections including meningitis. These fungi include Pneumocystis jiroveci. pneumonia ( previously known as Pneumocystis carinii or PCP), Aspergillus, and Cryptococcus. Most transplant recipients will receive antifungal medication to reduce the risk for developing fungal infectionsfor at least 3 months or longer after surgery.

A Timeline of Infection

Some infections are more likely to happen sooner (within the first 6 months after transplant surgery) rather than later. The Table below is a timeline of when to be on the lookout for certain infections.

Common Infections 0 to 4 Weeks After Surgery	Common Infections 1 to 6 Months After Surgery	Infections More Than 6 Months After Surgery
Wound infections Infection at catheter site Urinary tract infections Sinus infections Pneumonia Infectious diarrhea	Respiratory infections Urinary tract infections Herpes simplex virus Shingles Cytomegalovirus Epstein-Barr virus BK polyomavirus Skin warts Hepatitis B virus (recurrence) Hepatitis C virus (recurrence)	Respiratory infections Urinary tract infections Fungal infections Cytomegalovirus BK polyomavirus Shingles Herpes simplex virus

Keeping Your New Organ Safe

Infections can do more than make you sick. They can hurt your new organ and increase the risk of rejection. Even though your immune system has been "slowed down" by the anti-rejection drugs you are taking, there are many things you can do to prevent illness:

Stay away from people who show signs of being sick
Wash your hands frequently
Wear gloves when gardening
Avoid areas with mold, bird droppings, fresh fertilizer, or decaying plants (for example, compost heaps)
Avoid going barefoot
Use insect repellent especially at dawn and dusk
Clean cuts and scrapes with soap and water
Practice food safety (wash your hands before preparing food, after handling raw meat, and before you eat. Avoid consuming raw or undercooked foods and unpasteurized juices or milk)
Avoid cleaning out the litter box or birdcage. Try not to have contact with stray animals, chicks, baby ducks, and monkeys. These animals can carry diseases.
If traveling abroad, don’t drink tap water, ice or beverages made with tap water, fresh fruit juices, and unpasteurized milk or dairy products. Raw fruits and vegetables should also be avoided.

Vaccinations

Because anti-rejection drugs "slow down" your immune system and increase the risks of developing infections, you should stay up-to-date on vaccines that help prevent viral infections, including influenza (flu shot) and all of the routine "shots" that we receive as children. Your doctor may recommend routine annual vaccination against influenza and periodic vaccination against the pneumococal bacteria. Also, you should be vaccinated against hepatitis A and B. Members of your household should also receive routine vaccinations. The ideal time to vaccinate is prior to taking anti-rejection drugs when possible (although not all patients with chronic disease respond to vaccinations). After your transplant, the transplant team will probably recommend that you wait a certain amount of time before getting shots. In general, it is wise to wait for at least 6 months after transplantation or after an episode of acute rejection before receiving any vaccine.
With the exception of the live virus vaccinations, transplant patients can and should receive the same immunizations as nontransplant patients. Transplant recipients should probably not receive shots that use a live virus such as those used for chicken pox, measles, and mumps and the intranasal influenza vaccine . Your transplant team can tell you more. More information concerning vaccines is available at www.cdc.gov.
Vaccines that are widely considered safe when administered to patients taking anti-rejection drugs or their household contacts are listed below:

Diphtheria
Hepatitis A, B or the combination of A/B
Haemophilus influenzae type b (Hib)
Human papillomavirus
Influenza inactivated

Meningococcal
Pertussis
Pneumococcal
Tetanus
Tick-borne encephalitis

Alert Your Physician When Traveling

Travel can increase the risks of infection. Prior to traveling, transplant recipients should take certain precautions. Most importantly, tell your doctor that you are planning to travel. The Centers for Disease Control (CDC) provides general "Travelers' Health " information to assist travelers and their health care providers in deciding the vaccines, medications, and other measures necessary to prevent illness during international travel. Although this information is focused on the general traveling public, you can find useful information about vaccinations and disease outbreaks.
When traveling, you should take along additional supplies of required medications, like anti-rejection drugs, in case of loss. Consider packing some of your medications in carry-on luggage.
Lastly, make sure you have the contact addresses and phone numbers of the nearest transplant centers in the city/country of your destination.

Should You Be Concerned About Cancer?

Transplant recipients have a higher risk of developing certain types of cancers than people who have not had a transplant. Risk factors such as age, smoking and alcohol seem to play a role in the higher risk for malignancies, but taking anti-rejection drugs for a long time is the basis for the higher rate of some cancers. Some transplant recipients will develop skin cancer. Others may develop certain types of cancer of the lymph glands (lymphoma) and cancer of the cervix, which are caused by viruses. Transplant recipients also have a risk of developing other types of cancer such as breast cancer, lung cancer, and colon cancer. Regular medical exams to detect cancer are very important to your ongoing health and well-being.

Skin Cancers

Several types of skin cancers can occur more frequently in transplant recipients including squamous cell carcinomas (SCC), basal cell carcinomas and melanomas.

Figure. Types of Skin Cancer

Risk factors for skin cancer include anti-rejection therapy, sun exposure/ultraviolet radiation, and infection with human papillomavirus. Skin cancers in transplant recipients are more likely to occur at a younger age, be more aggressive, and metastasize. The risk of some skin cancers can be reduced. Some things you can do to decrease the chance of skin cancer include:

Limit the time you spend in the sun (especially when the sun is most intense between 10:00 am and 2:00 pm
Wear sunscreen (SPF 45 or higher)
Wear a wide-brimmed hat and gloves

Most skin cancers can be cured if detected early, so it is very important that you recognize the early signs of skin cancer and seek treatment if you notice anything unusual. A yearly visit to the dermatologist is also a good idea.

Virus-related Cancers

Some of the other malignancies that are more frequent after transplantation are those related to viral infection. These include Kaposi’s sarcoma (human herpes virus 8), anogenital lesions (human papillomavirus), carcinoma of the uterine cervix (human papillomavirus related), and posttransplant lymphoproliferative disorders (PTLD) and B-cell lymphomas (related to Epstein Barr virus).

Posttransplant Lymphoproliferative Disorder (PTLD)

Post-transplant lymphoproliferative disorder is a cancer of certain white blood and is related to some anti-rejection medications and the Epstein-Barr virus. This disorder can be treated by decreasing some anti-rejection medications, taking anti-viral medications, or chemotherapy.

Cancer Screening

While cancer can occur at any time, some malignancies, such as skin cancers and PTLD, are more likely to arise in the first couple years after transplant surgery.

Figure. When cancer most commonly occurs

The peak incidence of skin cancers 3–5 years after organ transplantation. Those cancers that are most common in the general population — breast, lung, colon cancer, etc. — tend to occur after a period of years.

Screening for breast, prostate and colon cancer should be performed at the appropriate sex, age and frequency as recommended by the American Cancer Society (ACS).

Figure. Cancer screening schedule

All transplant recipients should receive a thorough dermatologic exam yearly and should be educated on the use of sun screen and avoidance of sun exposure. If you do develop cancer, your transplant team will want you to see a specialist to treat the condition. You will also need to let your transplant team know if you are diagnosed with cancer.