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Once Upon A Time

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Kate Gould, FRCPath
Freeman Hospital
Newcastle upon Tyne, United Kingdom

Once upon a time there was a person who had a bad heart (or lungs). He was very poorly until a nice doctor came along and said she could make him better by taking out his old heart and plumbing in a new one. The operation took place, there were no complications and the person went back to living a normal life and lived happily ever after.

Of course this is a fairy tale, but I'm sure we would all want this for our patients. A full return to "normal" life should be the Holy Grail for our transplant teams, but sadly, even if we can get individuals back to normality from a physical perspective, there remains the issue of the immunosuppression.

We are all familiar with how immunosuppression works to preserve a transplanted organ and how that makes individuals more prone to certain infections, but how to we balance the positive with the negative when it comes to making lifestyle choices?

It is well known that T cell suppression makes you more prone to infections from environmental organisms such as Legionella and Aspergillus spp, but it can also make you more likely to become infected with some of the Zoonoses such as Brucella and Bartonella spp.

When I gave a short talk about this at the meeting in Montreal it was clear that no two transplant centres gave the same advice. So not to cause controversy (very difficult for me, I realise) I will just give my personal opinion, but maybe it's time for another ISHLT Monograph?

If a transplant recipient goes back to work, it can only be a good thing. In the UK, where healthcare is free, going back to work and paying taxes is beneficial to the health of the national economy.

Are there any professions which represent a completely unacceptable risk? There must be some, but I haven't found any yet. If someone wants to go back to farming, they can, so long as they are careful about hand hygiene and are risk averse. The biggest risk is poorly ventilated barns full of animals and dusty straw or Silage. Silage is partially rotted hay which is used widely as feed for over wintering livestock in Europe. It is full of aspergillus spores. The transplant recipient has to make sure that the barn is well ventilated before they enter, or get someone else to do this work for them. There is the possibility of portable ventilation helmets (see below).

Nursing and medicine are also acceptable now that everyone has to wash their hands properly and frequently for Infection Control purposes. Lung recipients will need to take extra care when caring for patients with cystic fibrosis colonised with resistant organisms. One of our recipients wanted to be a Microbiology technician. This was no problem as they are so well trained in terms of safety and even immunocompetant individuals are protected from aerosols by safety cabinets.

A recipient who has been ill all their life (or a very long time) will be keen to visit all those places that they were too poorly to visit before. Most transplant centres provide handbooks about immunisations and water safety. Live vaccines are prohibited which makes travel to or through countries with Yellow Fever impossible.

Canoeing in slow moving water may put folk at risk from Leptospirosis and potholing in bat infested caves would not be safe owing to the risk from fungal infections.

Transplant recipients are more susceptible to food poisoning, so those lovely buffets with luke warm, undercooked dishes may have to be given a miss.

There is not much in the transplant literature about sexually transmitted infection, but it must happen. Logic would suggest that that gonorrhoea and chlamydia are more likely to disseminate in the immunocompromised.

links imageNever in my career have I advised a potential transplant recipient that they will have to give up their pets. It's back to good hand hygiene again. Mouth to mouth resuscitation (or French kissing) another mammal may risk colonisation with Capnocytophagia which may cause an overwhelming infection, but it is so rare that it is not worth obsessing about. Animal bites are a completely different issue requiring urgent medical attention, prophylactic antibiotics plus tetanus (+/- rabies) shots.

In the UK some folk like to keep pigeons in dusty lofts. They really become attached to them. This is where the portable exhaust ventilation helmets come in useful.

We want our transplant patients to return to normal life as quickly as possible. Everything we do in life carries a potential risk. The risk of acquiring an infection may be greater in our patients but in the end it comes down to good old fashioned "common sense," something you have either got, or you haven't. If you lack common sense, no rules or protocols are ever going to keep you safe!

Disclosure Statement: The author has no conflicts of interest to disclose.

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