Persistent pyrexia post-liver transplantation: A unique case of pericardial tuberculosis

Abstract

A 60-year-old Caucasian woman was admitted into the hospital with a two-week history of dry cough, fever and breathlessness. There were no other complaints. She had an orthotopic liver transplant (OLT) three months previously for end-stage primary biliary cirrhosis (PBC) and was on azathioprine 125 mg and tacrolimus 9 mg per day. On examination, she was pale, tachycardic and temperature was 38.7 °C. There was medium to coarse crepitations in the left lung base. Initial investigations were: white cell count (WCC) 8.5 (NR 4–11×10/L), neutrophils 4.5 (NR: 2–7.5×10/L), lymphocytes 1.5 (NR 1.5– 4×10/L), haemoglobin (Hb) 7.1 (NR: 11–16 g/dL), platelets 375 (NR: 150–400×10/L), C-reactive protein (CRP) was 182 (NR: b10 mg/L), AST 86 (NR: 5–43 U/L), ALP 965 (NR: 70– 330 U/L), bilirubin 12 (NR:1–22 μmol/L) and creatinine 133 (NR: 50–111 μmol/L). Chest radiograph (CXR) showed clear lung fields but increased cardio-thoracic ratio (C: T=0.6). Blood, urine, sputum and stool cultureswere negative. Shewas started on intravenous tazocin (piperacillin–tazobactam) 4.5 g t.d.s. for a possible lower respiratory tract infection. Despite completing antibiotics, she remained unwell with swinging pyrexia (37.5 to 39 °C). Abdominal ultrasound scan was normal but a trans-thoracic echocardiogram confirmed loculated pericardial effusion. Pericardiocentesis provided symptomatic relief; pericardial fluid was sent for microscopy, culture and cytology. All were negative, including a Ziehl– Neilsen (ZN) stain. Peripheral blood cytomegalovirus (CMV) polymerase chain reaction (PCR) showed high viral loads at 1.7×10 copies/mL.