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de Oliveira PC, Braz Corbi MJDA, Siqueira AWDS, Navajasegaran J, Mesquita ASS, Frassetto FP, Jatene MB, Ikari NM, Azeka E. Brain tuberculoma in pediatric heart transplant recipient. Pediatr Transplant 2023; 27:e14496. [PMID: 36918295 DOI: 10.1111/petr.14496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 01/13/2023] [Accepted: 02/15/2023] [Indexed: 03/16/2023]
Abstract
INTRODUCTION Heart transplantation is the standard treatment for end-stage heart disease. Despite advances in the field, patients remain under risk of developing complications, including opportunistic infections, such as tuberculosis. We present the unprecedented case of cerebral tuberculoma in a 9-year-old heart transplant recipient. CASE SCENARIO A 9-year-old female child, who underwent heart transplantation in December 2020, was admitted to the emergency department in September 2021 due to headache and vomiting. She had normal vital signs and a mild left hemiparesis. Laboratory findings included lymphopenia and a low C Reactive Protein and brain images showed expansive lesions. A biopsy of the intracranial lesion was performed and anatomopathological analysis was compatible with tuberculoma. After the diagnosis was established, treatment protocol for neurotuberculosis was initiated, the patient had a satisfactory clinical evolution and was discharged 22 days after admission. DISCUSSION Clinical manifestation of tuberculosis usually occurs up to 6 months after transplantation, the findings are commonly atypical and symptoms may be mild. We could not find in medical literature any description of the disease in a heart transplant recipient as young as the one presented in this case report. We documented great response to treatment, even though conventional antituberculosis therapy may interfere with immunosuppression. CONCLUSION Patients in the postoperative period following heart transplantation are at high risk for developing opportunistic infections such as tuberculosis, which may present with atypical symptoms. Therefore the clinician must have a high index of suspicion in order to make the correct diagnosis and promptly start treatment.
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Affiliation(s)
| | | | | | | | | | | | | | - Nana Miura Ikari
- Heart Institute (InCor) University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Estela Azeka
- Heart Institute (InCor) University of Sao Paulo Medical School, Sao Paulo, Brazil
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Radisic MV, Pujato NR, Bravo PM, Del Grosso RC, Hunter M, Beltramino S, Linares González L, Cornet ML, Del Carmen Rial M, Franzini RL, Dotta AC, León LR, Walther J, Uva PD, Werber G. Tuberculosis treatment without rifampin in kidney/kidney-pancreas transplantation: A case series report. Transpl Infect Dis 2022; 24:e13949. [PMID: 36515463 DOI: 10.1111/tid.13949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/24/2022] [Accepted: 08/01/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The best approach to tuberculosis (TB) treatment in transplanted patients is still unknown. Current guidelines are based on evidence either extrapolated from other populations or observational. Rifampin-containing regimens have strong pharmacokinetic interactions with immunosuppressive regimens, with high rates of organ dysfunction and ∼20% mortality. This report describes the results obtained using non-rifampin-containing regimens to treat confirmed TB in adult patients with kidney/kidney-pancreas transplantation. METHODS Retrospective data analysis from confirmed TB cases in adult kidney/kidney-pancreas transplant recipients (2006-2019), treated "de novo" with non-rifampin-containing regimens. RESULTS Fifty-seven patients had confirmed TB. Thirty patients were treated "de novo" with non-rifampin-containing regimens. These patients' mean age was 49.24 (±11.50) years. Induction immunosuppression was used in 22 patients. Maintenance immunosuppression was tacrolimus-mycophenolate-steroids in 13 (43%), sirolimus-mycophenolate-steroids in 6 (20%), and other immunosuppressive regimens in 11 (36%). Belatacept was used in four patients. TB localizations: pulmonary 43%; disseminated 23%; extrapulmonary 33%. Twenty-seven (90%) patients completed treatment with isoniazid, ethambutol, and levofloxacin (12 months, 23; 9 months, 3; 6 months, 1); 12 of these patients also received pyrazinamide for the first 2 months and were cured with functioning grafts. One patient (3%) lost the graft while on treatment. Two patients (7%) died while on TB treatment. Median (range) follow-up after completion of TB treatment was 32 (8-150) months. No TB relapses were observed. CONCLUSIONS Results with non-rifampin-containing TB treatments in this case series were better (in terms of mortality and graft dysfunction) than those previously described with rifampin-containing regimens in transplanted patients.
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Affiliation(s)
- Marcelo Victor Radisic
- Infectious, Diseases Department, Instituto de Trasplante y Alta Complejidad (ITAC), Autonomous City of Buenos Aires, Argentina
| | - Natalia Rosana Pujato
- Infectious, Diseases Department, Instituto de Trasplante y Alta Complejidad (ITAC), Autonomous City of Buenos Aires, Argentina
| | - Pablo Martin Bravo
- Infectious, Diseases Department, Instituto de Trasplante y Alta Complejidad (ITAC), Autonomous City of Buenos Aires, Argentina
| | - Roxana Constanza Del Grosso
- Internal Medicine Department, Instituto de Trasplante y Alta Complejidad (ITAC), Autonomous City of Buenos Aires, Argentina
| | - Martin Hunter
- Internal Medicine Department, Instituto de Trasplante y Alta Complejidad (ITAC), Autonomous City of Buenos Aires, Argentina
| | - Santiago Beltramino
- Critical Care Unit, Instituto de Trasplante y Alta Complejidad (ITAC), Autonomous City of Buenos Aires, Argentina
| | - Laura Linares González
- Infectious, Diseases Department, Instituto de Trasplante y Alta Complejidad (ITAC), Autonomous City of Buenos Aires, Argentina
| | - María Lucía Cornet
- Infectious, Diseases Department, Instituto de Trasplante y Alta Complejidad (ITAC), Autonomous City of Buenos Aires, Argentina
| | - Maria Del Carmen Rial
- Kidney Transplantation Unit, Instituto de Trasplante y Alta Complejidad (ITAC), Autonomous City of Buenos Aires, Argentina
| | - Rosa Livia Franzini
- Kidney Transplantation Unit, Instituto de Trasplante y Alta Complejidad (ITAC), Autonomous City of Buenos Aires, Argentina
| | - Ana C Dotta
- Kidney Transplantation Unit, Instituto de Trasplante y Alta Complejidad (ITAC), Autonomous City of Buenos Aires, Argentina
| | - Luis Roberto León
- Kidney Transplantation Unit, Instituto de Trasplante y Alta Complejidad (ITAC), Autonomous City of Buenos Aires, Argentina
| | - Javier Walther
- Kidney Transplantation Unit, Instituto de Trasplante y Alta Complejidad (ITAC), Autonomous City of Buenos Aires, Argentina
| | - Pablo Daniel Uva
- Kidney-Pancreas Transplantation Unit, Instituto de Trasplante y Alta Complejidad (ITAC), Autonomous City of Buenos Aires, Argentina
| | - Gustavo Werber
- Critical Care Unit, Instituto de Trasplante y Alta Complejidad (ITAC), Autonomous City of Buenos Aires, Argentina
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Hosford JD, von Fricken ME, Lauzardo M, Chang M, Dai Y, Lyon JA, Shuster J, Fennelly KP. Hepatotoxicity from antituberculous therapy in the elderly: a systematic review. Tuberculosis (Edinb) 2014; 95:112-22. [PMID: 25595441 DOI: 10.1016/j.tube.2014.10.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 10/14/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND Elderly persons have the highest rates of tuberculosis (TB) in the United States compared to all other age groups. A systematic literature review was conducted to determine if older age was a risk factor for hepatotoxicity resulting from treatment with first-line drugs used to treat active (TB) and latent tuberculosis (LTBI). METHODS A systematic review of MEDLINE, Cochrane Controlled Trial Registry, CINAHL(®), and Science Citation Index Expanded (from 1970 to 2011) was performed to determine the risk of hepatotoxicity, comparing those over 60 with those under 60. A meta-analysis was performed using a random effects model along with log odds ratios and the chi-square test. FINDINGS Thirty-eight studies (40,034 participants; 1208 cases of hepatotoxicity) met the selection criteria. For active TB, an overall mean effect of 0.277 (p = 0.024, 95% CI: 0.037-0.517) was observed, which is equivalent to an odds ratio of 1.32 (95% CI: 1.04-1.68). For LTBI, an overall mean effect of 1.42 (p < 0.001, 95% CI: 0.794-2.05) was observed, which translates to an odds ratio of 4.14 (95% CI: 2.21-7.74). INTERPRETATION Our analysis revealed that patients older than 60 had significantly more risk of hepatotoxicity. These studies suggest that a gentler regimen of treatment for older individuals could benefit health outcomes in this population of TB patients and minimize risks to the public's health.
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Affiliation(s)
- Jennifer D Hosford
- Southeastern National Tuberculosis Center, Department of Medicine, University of Florida, Gainesville, FL, USA; Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Michael E von Fricken
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA; Department of Environmental and Global Health, University of Florida, Gainesville, FL, USA
| | - Michael Lauzardo
- Southeastern National Tuberculosis Center, Department of Medicine, University of Florida, Gainesville, FL, USA; Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Myron Chang
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Yunfeng Dai
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Jennifer A Lyon
- Biomedical and Health Information Services, University of Florida, Gainesville, FL, USA
| | - John Shuster
- Department of Health Outcomes and Policy, University of Florida, Gainesville, FL, USA
| | - Kevin P Fennelly
- Southeastern National Tuberculosis Center, Department of Medicine, University of Florida, Gainesville, FL, USA; Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA.
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Sattinger E, Meyer S, Costard-Jäckle A. Cutaneous tuberculosis mimicking erysipelas of the lower leg in a heart transplant recipient. Transpl Int 2011; 24:e51-3. [DOI: 10.1111/j.1432-2277.2011.01218.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Tuberculosis After Heart Transplantation: Twenty Years of Experience in a Single Center in Taiwan. Transplant Proc 2008; 40:2631-3. [DOI: 10.1016/j.transproceed.2008.08.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Sulemanjee NZ, Merla R, Lick SD, Aunon SM, Taylor M, Manson M, Czer LSC, Schwarz ER. The first year post-heart transplantation: use of immunosuppressive drugs and early complications. J Cardiovasc Pharmacol Ther 2008; 13:13-31. [PMID: 18287587 DOI: 10.1177/1074248407309916] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
A large number of heart transplants are performed annually in different transplant centers in the United States. This is partly because of the improved survival of patients who undergo cardiac transplantation, thus making it a more viable option in the management of end-stage heart failure. The survival benefit after heart transplantation is a result of newer immunosuppressive drug regimens and a better understanding of their effects and interactions. Several studies, mostly involving a small number of patients, describe use and comparison of the many distinct immunosuppressive drugs available to date. Interestingly, many transplant centers perform in-house typical induction treatment regimens because of their own experience and intra-institutional preference. This review summarizes current practices of immunosuppressive drug therapy in the first year post-heart transplant based on the available clinical evidence and discusses future options of heart transplant immunosuppressive drug therapies.
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Affiliation(s)
- Nasir Z Sulemanjee
- Division of Cardiology, Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, USA
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Bofinger JJ, Schlossberg D. Fever of unknown origin caused by tuberculosis. Infect Dis Clin North Am 2008; 21:947-62, viii. [PMID: 18061084 DOI: 10.1016/j.idc.2007.08.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Tuberculosis is an important cause of fever of unknown origin. Travel, age, dialysis, diabetes, birth in a country with a high prevalence of tuberculosis, and immunoincompetence are among the most salient risks. Associated physical findings, radiologic evaluation, and hematologic and endocrinologic abnormalities may provide clues to the diagnosis. Both noninvasive and invasive diagnostic modalities are reviewed. Because diagnosis may be elusive, therapeutic and diagnostic trials of antituberculous therapy should be considered in all patients with fever of unknown origin who defy diagnosis.
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Affiliation(s)
- Jason J Bofinger
- Section of Infectious Diseases, Temple University Hospital, Parkinson Pavilion, Philadelphia, PA 19140, USA
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Abstract
Isoniazid, pyrazinamide and rifampicin have hepatotoxic potential, and can lead to such reactions during antituberculosis chemotherapy. Most of the hepatotoxic reactions are dose-related; some are, however, caused by drug hypersensitivity. The immunogenetics of antituberculosis drug-induced hepatotoxicity, especially inclusive of acetylaor phenotype polymorphism, have been increasingly unravelled. Other principal clinical risk factors for hepatotoxicity are old age, malnutrition, alcoholism, HIV infection, as well as chronic hepatitis B and C infections. Drug-induced hepatic dysfunction usually occurs within the initial few weeks of the intensive phase of antituberculosis chemotherapy. Vigilant clinical (including patient education on symptoms of hepatitis) and biochemical monitoring are mandatory to improve the outcomes of patients with drug-induced hepatotoxicity during antituberculosis chemotherapy. Some fluoroquinolones like ofloxacin/levofloxacin may have a role in constituting non-hepatotoxic drug regimens for management of tuberculosis (TB) in the presence of hepatic dysfunction. Isoniazid administration is currently the standard therapy for latent TB infection. Rifamycins like rifampicin or rifapentine, alone or in combination with isoniazid, may also be considered as alternatives, pending accumulation of further clinical data. During treatment of latent TB infection, regular follow up is essential to ensure adherence to therapy and facilitate clinical monitoring for hepatic dysfunction. Monitoring of liver chemistry is also required for those patients at risk of drug-induced hepatotoxicity.
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Affiliation(s)
- Wing Wai Yew
- Tuberculosis and Chest Unit, Grantham Hospital, Hong Kong, China.
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Jung H, Oh YM, Lee SD, Kim WS, Kim DS, Kim WD, Kim JJ, Lee SG, Shim TS. Clinical Characteristics of Tuberculosis in Liver or Heart Transplant Recipients. Tuberc Respir Dis (Seoul) 2006. [DOI: 10.4046/trd.2006.61.5.440] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Hoon Jung
- Division of Pulmonary and Critical Care Medicine, Asan Medical Center, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeon-Mok Oh
- Division of Pulmonary and Critical Care Medicine, Asan Medical Center, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Do Lee
- Division of Pulmonary and Critical Care Medicine, Asan Medical Center, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo Sung Kim
- Division of Pulmonary and Critical Care Medicine, Asan Medical Center, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Soon Kim
- Division of Pulmonary and Critical Care Medicine, Asan Medical Center, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Dong Kim
- Division of Pulmonary and Critical Care Medicine, Asan Medical Center, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Joong Kim
- Division of Cardiology, Asan Medical Center, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Gyu Lee
- Division of Hepatopancreatobiliary Surgery and Liver Transplantation, Asan Medical Center, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Tae Sun Shim
- Division of Pulmonary and Critical Care Medicine, Asan Medical Center, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
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