TB AND SOLID ORGAN TRANSPLANT: THINK OUTSIDE OF THE LUNGS

Abstract

SESSION TITLE: Chest Infections 1 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTON: The incidence of Mycobacterium Tuberculosis (TB) is significantly higher among solid organ transplant recipients. Diagnosis requires a high level of suspicion, as transplant patients may present atypically or with extrapulmonary disease. Management can be difficult due to interactions between TB medications and immunosuppressive drugs. CASE PRESENTATION: A 66-year old Chinese man with a history of treated latent TB and cadaveric kidney transplant was admitted to the hospital with weakness, fever, blurred vision, and worsening left knee pain and swelling. Over the prior two months, he had presented to multiple urgent care centers with the same joint symptoms, for which he was treated with non-steroidal anti-inflammatory drugs. Knee X-ray had shown mild swelling. Patient’s immunosuppressive regimen included prednisone, mycophenylate mofetil, and tacrolimus. On admission, there was a mild leukocytosis, mildly elevated alkaline phosphatase level, and hypercalcemia. Computerized tomography of the chest (figure 1), abdomen and pelvis revealed diffuse pulmonary micro-nodules, gastric thickening, and a left knee effusion with possible osteomyelitis (figure 2). Magnetic resolution imaging of the brain showed evidence of optic neuritis (figure 3). Synovial fluid contained 12,300 white blood cells, with 87% neutrophils. Cerebrospinal fluid analysis was unremarkable. Smears and cultures for acid fast bacilli (AFB) were positive in samples from synovial fluid, sputum, stool, urine and blood. Treatment with rifabutin, isoniazid, ethambutol, pyrazinamide, and levofloxacin was initiated. Mycophenylate mofetil was discontinued, and treatment with tacrolimus was continued with close monitoring of drug levels. Drug levels for isoniazid and rifabutin were sub-therapeutic, and rifabutin and levofloxacin were then administered intravenously and amikacin added. Fevers resolved, visual acuity returned to normal, knee swelling improved, and tacrolimus levels remained in the therapeutic range. DISCUSSION: TB may present as monoarticular swelling of insidious onset, resulting in prolonged treatment delays. Solid organ transplant recipients with a history of latent TB infection or immigration from TB endemic areas are at increased risk, especially in the first year after transplant. Diagnosis requires prompt arthocentesis, which reveals a neutrophil-predominant effusion and AFB. Monitoring and adjustment of TB and immunosuppressive drug levels are critical. CONCLUSIONS: We present a case of disseminated tuberculosis presenting as monoarticular arthritis in a solid organ transplant patient. A high index of suspicion is essential to avoid treatment delays. Reference #1: Aguado JM, Torre-Cisneros J, Fortun J, Benito N, Meije Y, Doblas A, and Munoz P. Tuberculosis in solid-organ transplant recipients: consensus statement of the group for the study of infection in transplant recipients (GESITRA) of the Spanish Society of Infectious Diseases and Clinical Microbiology. Clin Infect Dis. 2009;48(9):1276-84. Reference #2: Sundaram M, Adhikary SD, John GT, Kekre NS. Tuberculosis in renal transplant recipients. Indian J Urol. 2008;24(3):396-400. DISCLOSURES: Scientific Medical Advisor relationship with Cohero Health Please note: $1-$1000 Added 03/05/2018 by Caralee Caplan-Shaw, source=Web Response, value=Ownership interestRemoved 03/05/2018 by Caralee Caplan-Shaw, source=Web Response Scientific Medical Advisor relationship with Cohero Health Please note: $1-$1000 Added 03/05/2018 by Caralee Caplan-Shaw, source=Web Response, value=shares No relevant relationships by Assad Oskuei, source=Web Response