*Purpose: Mycetoma are uncommon in lung transplant recipients (LTRs) and previous studies describe poor outcomes. We reviewed our experience

*Methods: Retrospective review of electronic medical records of LTRs from 0/1/01/2013-12/31/2020 at single center

*Results: Mycetoma was present in 0.6% (7/1086) LTRs: (3/7) pre-lung transplant(LT) and (4/7) post-LT. Mean age at LT was 65 years (yrs). Idiopathic pulmonary fibrosis (71%), interstitial lung disease (14%), and sarcoidosis (14%) were indications for LT. Serum Aspergillus galactomannan (AG) +ive in 29% while BAL AG was+ive in 57%. 3/7 of mycetoma were pre-LT and 4/7 were post. Computed tomography in all patients(pts) consistent with mycetoma. Pre-Lung Transplant Mycetoma: (2/3) underwent bilateral LT. Mean time between diagnosis (dx) of mycetoma and LT was 22 months (m) (5-36m). (2/3) had pre-LT respiratory culture (resp cx) (+) for Aspergillus fumigatus (AF), and 1 patient(pt) grew voriconazole (VOR) resistant AF. Mean duration of antifungal pre-LT was 10m (2-23m): intracavitary amphotericin (AMB) + inhaled AMB + posaconazole (POS) was used in pt with VOR-resistant AF. Surgical resection not done pre-LT. Explant histopathology with fungal hyphae in all LTRs. 1 pt with resp cx (+) AF at time of LT. All pts had negative post-LT resp cx and galactomannan (GM). Antifungal duration post-LT was a mean of 8.5m:[JL1] 1 pt POS; 1 pt VOR; 1 pt with azole-resistant AF with, intracavitary AMB irrigation, intravenous AMB (1m), Micafungin + Inhaled AMB +POS (16m). 6m mortality was 67%, none of which was due to fungal infection. Post-Lung Transplant Mycetoma: (4/4) underwent single LT and developed mycetoma in the native lung with dx at a mean of 54m (20-134m) post-LT. (3/4) developed mycetoma while on itraconazole prophylaxis. All pts had (+) resp cx (3 AF, 1 Pseudallescheria boydii (PD)). None had resp cx (+) pre-LT. Mean duration of treatment was 11m (1-18m). VOR used in all pts but switched to POS in 2: 1 for elevated liver enzymes and squamous cell cancer, and 1 for VOR resistance No surgical resection was done. 1 yr survival from time of mycetoma dx was 75%.Autopsy was not performed in any pt

*Conclusions: Mycetoma is rare in LTRs and was caused by AF and PD. Overall mortality in LTRs remains high but mycetoma was not the primary cause. Pre-LT mycetoma pts did not develop invasive fungal infection or mycetoma post-LT but were heavily treated post-LT. Post- LT mycetoma developed in native lung, and should be considered a rare risk in pts with single LT. Consider azole resistance testing in pts with mycetoma and previous azole exposure as this may impact antifungal therapy.Further studies for optimal antifungal and surgical management of mycetoma in LT are needed

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