Mycobacterium tuberculosis Infection in Solid Organ Transplant Recipients: Experience From a Single Center in China

Rifabutin for treating tuberculosis in solid organ transplant recipients: A retrospective observational study and literature review

BACKGROUND

The treatment of tuberculosis (TB) in solid organ transplant (SOT) recipients is challenging owing to interactions between rifampin and immunosuppressive drugs. Rifabutin, a rifamycin with excellent activity against Mycobacterium tuberculosis and that induces cytochrome p450 less, may facilitate treatment. We report our experience with rifabutin for treating TB in SOT recipients and review the available literature.

METHODS

A retrospective observational study of all SOT recipients with TB between January 2000 and December 2019. The clinical characteristics and outcomes of patients treated with and without rifabutin-containing regimens were compared and a literature review was conducted.

RESULTS

We included 31 SOT recipients with TB, among whom 22 (71%) were men and the median age was 62 years (interquartile range 50-20). There were no significant differences between patients treated with rifabutin (n = 12), rifampin (n = 14), and non-rifamycins (n = 5) in clinical cure rates (83.3%, 64.3%, and 100%, respectively; P = .21), side effects (25%, 37.5%, and 20%, respectively; P = .74), or mortality (16.7%, 35.7%, and 0%, respectively; P = .21). Only one patient, treated with rifampin, suffered graft rejection. The literature review identified 59 SOT recipients with TB treated with rifabutin-containing regimens from 8 publications. Overall, the clinical cure, graft rejection, and mortality rates were 93.2%, 5.1%, and 6.8%, respectively.

CONCLUSIONS

Rifabutin-containing regimens offer a reliable alternative to rifampin when treating TB in SOT recipients.

Therapeutic effect of minimally invasive catheter drainage and local chemotherapy for the lumbosacral tuberculosis without neural symptoms

Increasing number of studies have shown growing incidence of lumbosacral tuberculosis and its complications. However, the treatment options for this disorder are still limited.To evaluate the long-term therapeutic effect and prognosis of minimally invasive puncture catheter drainage and Isoniazid local chemotherapy for the treatment of lumbosacral tuberculosis without neural symptoms under the guidance of computed tomography (CT).A total of 45 patients with asymptomatic lumbosacral tuberculosis were treated by minimally invasive catheter drainage under CT guidance. Forty-two cases had been followed up, which included 22 women and 20 men with an average age of 36.45 years old. Isoniazid was injected locally and antituberculotic drugs were administered for postoperative treatment. Oswestry Disability Index (ODI), visual analogue scale (VAS) evaluation and Cobb angle were recorded before and after operation.Forty-two patients had been followed up and the follow-up term was from 1.2 to 8.5 years (average 60 months). All patients were healed without recurrent cases. The ODI were improved from 14.86 ± 2.02 before operation to 1.48 ± 1.55 after operation. The post-operative (4.19 ± 1.17) VAS score was improved compared to the pre-operative VAS score (0.55 ± 0.55). The post-operative Cobb angle (6.19° ± 3.85°) was also improved relatively to the preoperative Cobb angle (5.90° ± 3.71°).Minimally invasive puncture catheter drainage combined with Isoniazid local chemotherapy is an effective method for lumbosacral tuberculosis without neural symptom. Meanwhile, it can be applied for the treatment of spinal tuberculosis before open surgery.

Incidence, Outcomes, and Long-term Immune Response to Tuberculosis in Organ Transplant Recipients

BACKGROUND

Tuberculosis (TB) is a significant opportunistic infection in solid organ transplant recipients (SOTR). There are limited data on TB incidence in transplantation from low prevalence countries as well as on long-term TB-specific immune responses.

METHODS

We performed a single-center retrospective review of SOTR diagnosed with active TB between 2000 and 2015 and further contacted the available patients for a study of long-term T-cell responses using an interferon-gamma (IFN-γ) release assay and a flow cytometry-based assay.

RESULTS

We identified 31 SOTR with active TB for an incidence of 62 cases/100 000 patient-years. Nineteen (61.3%) of 31 patients were diagnosed within the first year after transplant. Nineteen (61.3%) were born in countries with high TB prevalence and disseminated disease occurred in 22.6%. No patient had been screened for latent TB infection pretransplant. The majority of patients received isoniazid and a rifamycin as part of multidrug regimen. In addition, 13 (44.8%) of 29 patients received quinolones. One-year mortality in this population was 19.4%. Eight patients were available for long-term immune responses. Of these, all had detectable IFN-γ response by IFN-γ release assay testing and 7 of 8 had detectable TB-specific T cells, primarily central and effector T-cell responses in the CD4 compartment and terminally differentiated T cells in the CD8 compartment.

CONCLUSIONS

TB has high incidence in SOTR even in low-prevalence regions but especially targets patients who originated from TB-endemic countries. Long-term TB-specific T-cell responses were found in the majority of patients.

Mycobacterial Infections in Patients With Chronic Kidney Disease and Kidney Transplantation

Patients with chronic kidney disease have impaired immunity that increases their risk of infection. Increased incidence of mycobacterial infections, in particular Mycobacterium tuberculosis, is described in patients undergoing hemodialysis and peritoneal dialysis as well as after kidney transplantation in low-prevalence and high-prevalence settings. Diagnosis of this infection can be challenging because of atypical presentations that may lead to treatment delay and, consequently, increased mortality; however, recent advances in molecular testing have improved diagnostic accuracy. It is imperative to try to identify those patients at increased risk and offer adequate prophylaxis. There are controversies and insufficient data regarding treatment agents, duration, and dosages. Most studies in nontuberculous mycobacteria are based on case series and retrospective studies.

Mycobacterium tuberculosis after solid organ transplantation: A review of more than 2000 cases

BACKGROUND

Mycobacterium tuberculosis (TB) is a common pathogen worldwide, and it may cause significant infection after solid organ transplantation (SOT). We reviewed all reported TB cases to provide an update on its epidemiology, clinical presentation, management, and outcome after SOT.

METHODS

MEDLINE, EMBASE, and OVID were reviewed from January 1, 1998, to December 31, 2016, using keywords tuberculosis and solid organ transplant or transplantation.

RESULTS

There were 187 publications reporting 2082 cases of TB among kidney (n = 1719), liver (n = 253), heart (n = 77), lung (n = 25), and kidney-pancreas (n = 8) recipients. Among cohort studies, the median incidence was 2.37% (range, 0.05%-13.27%) overall. Most TB disease was considered reactivation of latent infection, occurring beyond the first year after SOT. Early-onset cases were seen among donor-derived TB cases. Fever was the most common symptom. Radiologic findings were highly variable. Extrapulmonary and disseminated TB occurred 29.84% and 15.96%, respectively. Multidrug-resistant TB was rare. Treatment using 4 or 5 drugs was commonly associated with hepatotoxicity and graft dysfunction. All-cause mortality was 18.84%.

CONCLUSIONS

This large review highlights the complexity of TB after SOT. Reactivation TB, donor-transmitted infection, extrapulmonary involvement, and disseminated disease are common occurrences. Treatment of TB is commonly associated with hepatotoxicity and graft dysfunction.

Tuberculosis and Transplantation

Mycobacterium tuberculosis is a major opportunistic pathogen in transplant recipients. Compared to that in the general population, the frequency of tuberculosis (TB) is 10 to 40 times higher in hematopoietic stem cell transplant (HSCT) recipients and 20 to 74 times higher in solid-organ transplant (SOT) recipients. Transplant recipients with TB are also more likely to develop disseminated disease, have longer time to definitive diagnosis, require more invasive diagnostic procedures, and experience greater anti-TB treatment-related toxicity than the general population. Specific risk factors for TB in SOT recipients include previous exposure to M. tuberculosis (positive tuberculin skin tests and/or residual TB lesions in pretransplant chest X ray) and the intensity of immunosuppression (use of antilymphocyte antibodies, type of basal immunosuppression, and intensification of immunosuppressive therapy for allograft rejection). Risk factors in HSCT recipients are allogeneic transplantation from an unrelated donor; chronic graft-versus-host disease treated with corticosteroids; unrelated or mismatched allograft; pretransplant conditioning using total body irradiation, busulfan, or cyclophosphamide; and type and stage of primary hematological disorder. Transplant recipients with evidence of prior exposure to M. tuberculosis should receive treatment appropriate for latent TB infection. Optimal management of active TB disease is particularly challenging due to significant drug interactions between the anti-TB agents and the immunosuppressive therapy. In this chapter, we address the epidemiology, clinical presentation, diagnostic considerations, and management strategies for TB in SOT and HSCT recipients.

Gastrointestinal Tuberculosis

Gastrointestinal tuberculosis (TB) is a fascinating disease which can be observed both in the clinical context of active pulmonary disease and as a primary infection with no pulmonary involvement. It represents a significant clinical challenge because of the resurgence of TB as well as the diagnostic challenges it poses. A high clinical suspicion remains the most powerful tool in an era of medicine when reliance on diagnostic technology increases. Antimicrobial therapy is the mainstay of therapy, but surgical and endoscopic interventions are frequently required for intestinal TB. Gastrointestinal TB is truly the "great mimic" and continues to require the astute clinical acumen of skillful clinicians to diagnose and treat.

Tuberculosis After Renal Transplant

Tuberculosis is one of the leading infections after renal transplant, particularly in developing countries where the incidence and prevalence in the general population are high. Diagnosis requires bacteriologic and histologic confirmation. Interactions among the antitubercular drugs and the immunosuppressive agents have to be considered while prescribing, and surveillance for adverse effects is required. Although rare, case reports are available on extrapulmonary tuberculosis in allograft recipients. Here, we present a 25-year-old kidney transplant recipient who was diagnosed with lymph node tuberculosis under uncommon circumstances but who had a good outcome. This case report illustrates the difficulties in diagnosis of tuberculosis, changes in therapeutic protocols, and prognostic factors and highlights the effects of infectious complications with immunosuppressive therapy in this particular patient population.

High-resolution CT findings of pulmonary Mycobacterium tuberculosis infection in renal transplant recipients

OBJECTIVE

Renal transplantation recipients are at increased risk of Mycobacterium tuberculosis infection because of immunosuppression. The aim of this study was to assess high-resolution CT (HRCT) findings in renal transplantation recipients diagnosed with pulmonary tuberculosis (TB).

METHODS

We reviewed HRCT findings from patients diagnosed with pulmonary TB, established by M. tuberculosis detection in bronchoalveolar lavage, sputum or biopsy sample. Two observers independently reviewed HRCT images and reached consensus decisions on the presence and distribution of: (i) miliary nodules, (ii) cavitation and centrilobular tree-in-bud nodules, (iii) ground-glass attenuation and consolidation, (iv) mediastinal lymph node enlargement and (v) pleural effusion.

RESULTS

The sample comprised 40 patients [26 males, 14 females; median age, 45 years (range, 12-69 years)]. The main HRCT pattern was miliary nodules (40%), followed by cavitation and centrilobular tree-in-bud nodules (22.5%), ground-glass attenuation and consolidation (15%), mediastinal lymph node enlargement (12.5%) and pleural effusion (10%). The distribution of findings in patients with miliary nodules was random. In patients with cavitation and centrilobular tree-in-bud nodules, 66.6% of abnormalities were found in the upper lobes. Pleural effusion was unilateral in 75% of cases. The overall mortality rate was 27.5%. This rate was 50% in patients with miliary nodules, and 72.6% of all deaths occurred in this group. Thus, mortality was increased significantly in patients with miliary nodules (p < 0.05).

CONCLUSION

The main HRCT finding in renal transplantation recipients with pulmonary TB was miliary nodules, followed by cavitation and centrilobular tree-in-bud nodules. Miliary nodules were associated with a worse prognosis in these patients.

ADVANCES IN KNOWLEDGE

We report the first series on HRCT findings of microbiologically confirmed pulmonary TB exclusively in renal transplantation recipients. The main HRCT finding was miliary nodules, and mortality was increased significantly in these patients.

Risk factors for hepatotoxicity in solid organ transplants recipients being treated for tuberculosis

BACKGROUND

Tuberculosis (TB) is associated with high morbidity and mortality in solid organ transplant (SOT) recipients. Also, SOT patients have a 20- to 74-fold increase in the chance of developing TB compared to the general population. Here we evaluated the incidence of hepatotoxicity in SOT recipients on treatment for TB and determined risk factors for liver toxicity in these patients.

PATIENTS AND METHODS

Retrospective cohort conducted in a reference hospital for SOT in Southern Brazil. All SOT recipients who underwent TB treatment during the years 2000-2012 were considered for the study.

RESULTS

A total of 69 patients were included in the study and 23 had liver toxicity (incidence 33.3%). Independent risk factors for hepatotoxicity were rifampin use at doses of ≥600 mg daily (P = .016; OR 2.47; 95% CI, 1.18-5.15) and lung transplantation (P = .017; OR 2.05; 95% CI, 1.14-3.70). Kidney transplantation appeared as a protective factor (P = .036; OR 0.50; 95% CI, 0.26-0.96). Mortality was higher in the patients who had hepatotoxicity (43.5%), compared with those who did not (19.6%).

CONCLUSION

In this study, the use of rifampin at doses of 600 mg daily or higher was found to be an independent risk factor for liver toxicity in SOT recipients. The importance of additional risk factors for hepatotoxicity, such as lung transplantation as well as the protective role of kidney transplantation, should be better investigated in SOT recipients being treated for TB.

Tuberculosis in liver transplant recipients: experience of a South Indian liver transplant center

Tuberculosis (TB) is a serious disease for liver transplant recipients (LTRs). Data on post-liver transplant TB from high-burden countries are scant. The aims of this study were to describe the prevalence of TB in LTRs from a high-prevalence area and to analyze the risk factors for the development of post-liver transplant TB. We performed a retrospective review of our database and a case-control study of identified cases with TB and age-matched LTRs without TB. The overall prevalence of TB in LTRs was comparable to the prevalence of TB in LTRs from low-prevalence countries (5/214 or 2.3%). A low rate of interferon-γ release assay (IGRA) testing before liver transplantation was observed (68/214 or 31%). Most patients were screened clinically and with chest radiography alone before transplantation. TB developed variably after transplantation [median = 72 days, interquartile range (IQR) = 534 days]. The presentation was mostly extrapulmonary and/or disseminated (4/5 or 80%). When cases with posttransplant TB were compared with matched healthy LTRs, the presence of unexplained granulomas in explants (2/5 or 40%, P = 0.01) was the only factor associated with the development of TB. When all explants showing granulomas were reviewed, TB (52.9%) remained the most common cause; however, in almost half (47.1%), other attributable causes were found. Patients were treated with a standard daily regimen for a median of 12 months (IQR = 7.5 months). Posttransplant TB was associated with a high mortality rate (2/5 or 40%). In conclusion, we observed a low prevalence of TB in LTRs from a high-prevalence region. The presence of granulomas suggestive of TB in liver explants warrants isoniazid prophylaxis in the absence of disease. Post-liver transplant TB is associated with a high mortality rate. The roles of routine IGRA testing and isoniazid prophylaxis in a high-prevalence setting urgently need to be studied.

Mycobacterium tuberculosis infection following kidney transplantation

Introduction and Aims. Post-transplant tuberculosis (TB) is a problem in successful long-term outcome of renal transplantation recipients. Our objective was to describe the pattern and risk factors of TB infection and the prognosis in our transplant recipients. Patients and Methods. This study was a retrospective review of the records of 491 renal transplant recipients in our hospital during the period from January 1986 to December 2009. The demographic data, transplant characteristics, clinical manifestations, diagnostic criteria, treatment protocol, and long-term outcome of this cohort of patients were analyzed. Results. 16 patients (3,2%) developed post-transplant TB with a mean age of 32,5 ± 12,7 (range: 13–60) years and a mean post-transplant period of 36,6months (range: 12,3 months–15,9 years). The forms of the diseases were pulmonary in 10/16 (62,6%), disseminated in 3/16 (18,7%), and extrapulmonary in 3/16 (18,7%). Graft dysfunction was observed in 7 cases (43,7%) with tissue-proof acute rejection in 3 cases and loss of the graft in 4 cases. Hepatotoxicity developed in 3 patients (18,7%) during treatment. Recurrences were observed in 4 cases after early stop of treatment. Two patients (12.5%) died. Conclusion. Extra pulmonary and disseminated tuberculosis were observed in third of our patients. More than 9months of treatment may be necessary to prevent recurrence.

Tuberculosis of the genitourinary system-Urinary tract tuberculosis: Renal tuberculosis-Part II

This article reviews the computed tomography and magnetic resonance imaging (MRI) features of renal tuberculosis (TB), including TB in transplant recipients and immunocompromised patients. Multi detector computed tomography (MDCT) forms the mainstay of cross-sectional imaging in renal TB. It can easily identify calcification, renal scars, mass lesions, and urothelial thickening. The combination of uneven caliectasis, with urothelial thickening and lack of pelvic dilatation, can also be demonstrated on MDCT. MRI is a sensitive modality for demonstration of features of renal TB, including tissue edema, asymmetric perinephric fat stranding, and thickening of Gerota's fascia, all of which may be clues to focal pyelonephritis of tuberculous origin. Diffusion-weighted MR imaging with apparent diffusion coefficient (ADC) values may help in differentiating hydronephrosis from pyonephrosis. ADC values also have the potential to serve as a sensitive non-invasive biomarker of renal fibrosis. Immunocompromised patients are at increased risk of renal TB. In transplant patients, renal TB, including tuberculous interstitial nephritis, is an important cause of graft dysfunction. Renal TB in patients with HIV more often shows greater parenchymal affection, with poorly formed granulomas and relatively less frequent findings of caseation and stenosis. Atypical mycobacterial infections are also more common in immunocompromised patients.

Pulmonary infections in transplant recipients

PURPOSE OF REVIEW

Hematopoietic stem cell as well as solid-organ transplantation is being carried out with increasing frequency throughout the world. Lower respiratory tract infections (LRTIs) remain a common life-threatening complication faced by the transplant recipients. The purpose of this review is to provide up-to-date information on pulmonary infections among the transplant recipients, especially emphasizing the endemicity of microorganisms, epidemiology, work-up of infections, and principles of their management.

RECENT FINDINGS

A lower respiratory tract infection such as pneumonia is the most frequent of all the infections and is associated with high morbidity and mortality. Factors increasing the risk of pulmonary infections include surgical techniques, immune status, chemoradiotherapy, alloimmune mechanisms between the host and the graft, and the environment. A high degree of suspicion, computed tomography (CT) scan of the chest, and flexible bronchoscopy are required in most to establish the diagnosis.

SUMMARY

Proper management of LRTI in transplant recipients requires a high degree of suspicion, thorough knowledge of the epidemiology and endemicity of the suspected organisms, CT scan of the chest, and expertise at bronchoscopy. Utmost teamwork among transplant physicians, infectious disease specialist, and bronchoscopist is essential.

Tuberculosis in renal transplant recipients: the evidence for prophylaxis

BACKGROUND

Tuberculosis (TB) remains a leading cause of death in endemic countries and is 20 to 70 times more common in renal transplant recipients, where it contributes to both increased morbidity and mortality. This review will focus on the epidemiology of TB in renal transplant recipients and critically appraise the published literature on isoniazid prophylaxis in renal transplantation.

METHODS

A literature search for randomized and nonrandomized studies investigating the use of isoniazid prophylaxis in renal transplant recipients was conducted using Ovid MEDLINE, the Cochrane Library, the Transplant Library, and EMBASE. Relative risks (RRs) with 95% confidence intervals (CIs) are reported. Meta-analysis of the randomized controlled trials (RCTs) was performed with a fixed-effects model.

RESULTS

Eleven relevant studies were identified; six nonrandomized and five RCTs. The nonrandomized studies indicate a reduced risk of TB with isoniazid prophylaxis. The RCTs demonstrated conflicting results, with two studies finding a reduction in TB with prophylaxis and two studies finding no difference. Meta-analysis of the 709 patients from the four RCTs demonstrated a reduced risk of TB with isoniazid prophylaxis (RR, 0.31; 95% CI, 0.19-0.51). No significant difference was found in the incidence of hepatitis (RR, 1.22; 95% CI, 0.91-1.65).

CONCLUSION

Both randomized and nonrandomized studies support the value of isoniazid as TB prophylaxis in renal transplant recipients at risk of active infection. Clinicians should consider prophylaxis in renal transplant recipients in endemic areas or in recipients in nonendemic countries who are at risk. However, the evidence for the benefit of isoniazid prophylaxis in renal transplantation is not robust and there is still a need for a large multicenter trial of isoniazid prophylaxis in kidney transplantation in an endemic area.

Mycobacterium tuberculosis infection in liver transplantation

Mycobacterium tuberculosis can cause significant infections in liver transplant candidates and recipients. Its nonspecific clinical features and prolonged growth time in culture make the diagnosis difficult, and treating tuberculosis (TB) remains challenging because of significant toxicities and drug-drug interactions. The diagnosis of a latent TB infection may be accomplished with tuberculin skin testing and with the newer interferon-γ release assays, although this infection may be underrecognized because of host factors. Latent TB should be treated, but the degree of liver failure and the likelihood of progression to active TB will dictate whether this should occur before or after transplantation. Patients who have a history of TB, have used muromonab-CD3 or anti-T lymphocyte antibodies, or have experienced allograft rejection or coinfection with cytomegalovirus, Pneumocystis jiroveci, or Nocardia are at the greatest risk of developing active TB. Active TB in transplant patients is difficult to treat because of drug-induced hepatotoxicity and the significant interaction between rifampin and calcineurin inhibitors. In this article, we review the epidemiology, clinical features, and evaluation of transplant candidates and recipients. In addition, we offer recommendations on the appropriate diagnostic and treatment regimens for patients with latent and active TB infections.

Incidence and management of mycobacterial infection in solid organ transplant recipients

Although advances in surgical technique, immunosuppressive regimens, and medical management have led to improved survival and quality of life after solid organ transplantation, infection continues to represent a major cause of morbidity and mortality in transplant recipients. Immunosuppressive therapy after transplantation compromises cell-mediated immunity in particular, leaving the patient at risk for opportunistic as well as routine community-acquired infections. Mycobacterial infection is a rare but important complication of solid organ transplantation, presenting significant risk to the patient and challenges in terms of treatment. The available literature consists predominantly of case reports and institutional experiences. This article examines both Mycobacterium tuberculosis and nontuberculous mycobacterial infection in the transplant setting.

Mycobacterium tuberculosis infection in transplant recipients: early diagnosis and treatment of resistant tuberculosis

PURPOSE OF REVIEW

To provide a better understanding and summarize recent advances in the diagnosis and treatment of Mycobacterium tuberculosis (MTB) infection in solid organ transplant (SOT) candidates and recipients.

RECENT FINDINGS

Despite advances in SOT medicine, MTB causes substantial morbidity and mortality in SOT recipients, with reported prevalence rates of 0.4-6%. The primary source of posttransplant MTB is reactivation of pretransplant latent MTB infection. The short-term mortality rate in SOT recipients with drug-susceptible active MTB is 30%. In immunocompromised persons with extensively drug-resistant MTB, the mortality rate approaches 100%. Clinical presentation is often atypical with more than half of SOT recipients presenting with extrapulmonary or disseminated disease. Pretransplant latent MTB infection screening and treatment is the cornerstone for preventing reactivation and dissemination of active MTB posttransplant. Treatment of active MTB in SOT recipients is problematic, given significant drug toxicity and interaction with immunosuppressive agents.

SUMMARY

A high degree of suspicion for latent and active MTB infection in SOT candidates and recipients is warranted to establish a timely diagnosis and initiate life-saving appropriate therapy.

Tuberculosis in solid organ transplant recipients at a tertiary hospital in the last 20 years in Barcelona, Spain

OBJECTIVE

Mycobacterium tuberculosis (TB) is a serious opportunistic infection in solid organ transplant recipients. The TB incidence is 20 to 74 times greater than that among the general population. Our aim was to determine the incidence as well as the clinical, radiological, and microbiological features and outcomes of TB in these patients.

MATERIALS AND METHODS

We reviewed the clinical records of subjects with posttransplant TB from January 1988 to December 2007. A definite TB case was defined by a positive culture; probable TB by a positive smear or histological finding; and disseminated TB when 2 organs were involved. We noted an early diagnosis as ones in the first year posttransplantation. Outcomes were classified following the WHO recommendation and mortality related defined by death during treatment.

RESULTS

Among 4634 recipients (2757 kidney, 1334 liver, 361 double kidney-pancreas, and 182 heart), 21 (0.45%) developed posttransplant TB: namely, 0.47%, 0.22%, 1.1%, and 0.54%, respectively. In 2 cases M. tuberculosis did not grow upon culture; the diagnosis was established by positive acid-fast bacilli on a sputum smear or by histological findings on biopsy. The mean posttransplantation time to TB diagnosis was 21 months (48% early TB). Two patients had a previous history of TB. Fever was the most common symptom (71%). Pulmonary tuberculosis represented 47.6% of cases; extrapulmonary, 28.6%; and disseminated, 23.8%. Among the cases of pulmonary TB, 60% had unilateral infiltrates and 10% cavitations on X ray. Eighteen patients completed treatment. Five patients displayed adverse events, 3 of which were liver toxicity. Four patients died, with 3 deaths related to TB.

CONCLUSIONS

The incidence of TB in this cohort was higher than that among the general population (450 cases/100,000 recipients). TB was associated with adverse effects of treatment and significant mortality.