Tuberculosis in Liver Transplant Recipients: A Report of Eight Cases During a Five Year Period.

Abstract

Tuberculosis incidence in Portugal ranged from 20 to 22 cases per 100 000 inhabitants between 2010 and 2014.Tuberculosis incidence in liver transplant recipients is not precisely known, but it is estimated to be higher than among the generalpopulation. Tuberculosis in liver transplant recipients is particularly challenging because of the atypical clinical presentation and sideeffects of the antibacillary drugs and their potential interactions with immunosuppressive therapies. We retrospectively reviewed the clinical records of liver transplant recipients with post-transplant tuberculosisoccurring from January 2010 to December 2014 at a liver transplantation unit in Lisbon, Portugal. Demographic data, baseline andclinical features, as well as treatment regimen, toxicities and outcomes, were analyzed. Among 1005 recipients, active tuberculosis was diagnosed in eight patients between January 2010 and December 2014(frequency = 0.8%). Late onset tuberculosis was more frequent than early tuberculosis. Mycobacterium tuberculosis complex wasisolated from cultures in almost every case (7; 87.5%). Extra-pulmonary involvement and disseminated tuberculosis were frequent. Twopatients developed rejection without allograft loss. Crude mortality was 37.5%, with 2 deaths being related to tuberculosis. Despite the uncertainty regarding treatment duration in liver transplant recipients, disease severity, as well as number ofactive drugs against TB infection, should be taken into account. There was a need for a rifampin-free regimen and immunosuppressionadjustment in patients who experienced acute graf rejection. Although the number of cases of tuberculosis is low, its post-transplant frequency is significant and the observed mortalityrate is not to be neglected. The cases of hepatotoxicity and graft rejection seen in this case series demonstrate the challengesassociated with tuberculosis diagnosis in liver transplant recipients and management of the interactions between immunosuppressorsand rifampin. This study strengthens the recommendation of latent tuberculosis infection screening and treatment in liver transplantcandidates or recipients.