Genitourinary tuberculosis after renal transplantation-a report of three cases with a good clinical outcome

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.

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.

Abdominal tuberculosis following kidney transplantation: clinicopathologic features and follow-up in a unique case series

BACKGROUND

Kidney transplant recipients are at a high risk of opportunistic infection. The aims of this study were to describe the epidemiology, clinical features, and prognosis of abdominal tuberculosis (TB) in kidney transplant recipients.

METHODS

All cases of abdominal TB that occurred in kidney transplant recipients at our center between 1998 and 2010 were retrospectively reviewed. Detailed demographic data, clinical profile information, and the treatment response were recorded.

RESULTS

Among the 7833 kidney transplantations performed during the study period, eight patients (0.1%) developed abdominal TB. There were four men and four women in this group. The mean age of the patients was 44 ± 12 yr. The time from kidney transplantation to TB was 6.7 ± 3.4 yr. The symptoms were weight loss (87.5%), diarrhea (87.5%), fever (75%), abdominal pain (62.5%), and lower gastrointestinal bleeding (37.5%). The delay between the identification of the clinical symptoms and the diagnosis was an average of six months. The diagnosis was confirmed histopathologically for most patients. The cecum and ascending colon were the most common sites involved. Two patients required surgical intervention. Five patients received a 4-drug regimen, and three had hepatotoxicity. The median length of antituberculous therapy was nine (6-12) months. Five patients lost their graft. Overall, the hospital mortality was 12.5%.

CONCLUSIONS

Kidney transplantation increases the risk of TB, particularly as an extrapulmonary disease. The symptoms of infection are often attenuated, leading to delayed diagnosis. Therefore, a careful approach to the patient and supportive data are necessary to make the final and timely diagnosis.

Tuberculosis in renal transplant recipients

Infective complications are common after renal transplantation. Tuberculosis (TB) is one of the leading infections following renal transplantation. Reactivation is the most common mode of infection. The factors responsible for this reactivation are chronic liver disease, other coexisting infections, particularly deep mycoses, pneumocystis pneumonia, nocardia, and CMV infections. Cyclosporine use advances the onset of TB to an earlier date. The median onset following transplantation is estimated to be 26 months for those who receive azathioprine and prednisolone as immunosuppression and 11 months for those who receive cyclosporine along with other immunosuppressive agents. Lung is the major site of involvement. Pyrexia of unknown origin is another common presentation. Culture and sensitivity has to be done in all possible cases. Amongst the serological techniques, Interferon alpha production is emerging as the most important. Rifampicin has to be avoided in allograft recipients as it activates cytochrome-P450 enzymes and thereby decreases the therapeutic levels of cyclosporine and prednisolone. The duration of treatment is usually extended for 18 months followed by secondary prophylaxis with isoniazid. Adverse effects of drugs are more often reported in organ recipients and have to be monitored for. Drug resistance is emerging as a problem and appropriate changes in the management have to be carried out.

Allograft and prostatic involvement in a renal transplant recipient with disseminated tuberculosis

Tuberculosis is a serious opportunistic infection in renal transplant recipients and is disseminated in nature in one-third of patients. Genito urinary tuberculosis is rare in renal transplant recipients. We report a patient presenting 5 years after renal transplantation with disseminated tuberculosis and allograft and prostatic involvement.

Evaluation for granulomatous inflammation on fine needle aspiration cytology using special stains

Background. Tuberculosis is the commonest infectious disease in the developing world. Many diagnostic tests are devised for its detection including direct smear examination. This study was designed to determine the frequency of cases positive for AFB and positive for fungus in patients diagnosed to have granulomatous inflammation on Fine Needle Aspiration Cytology using special stains. Materials and Methods. A descriptive cross-sectional survey was done on 100 cases of granulomatous inflammation consistent with tuberculosis diagnosed on fine needle aspiration cytology at the Department of Pathology, King Edward Medical University, Lahore. After reporting granulomatous inflammation on Hematoxylin & Eosin staining of aspirates from FNAC, some unstained slides were subjected to special stains, like ZN, GMS, and PAS. Cases positive for AFB on ZN stain and fungus on GMS/PAS were noted down along with their frequency and percentages. Results. Forty-four cases (44%) of AFB positive smears were reported in granulomatous inflammation while only 5% cases of fungus were reported down. Cervical lymph nodes were the most commonly involved site (87%), and females were affected more (62%) than males. Most cases of AFB-positive smears were associated with caseation necrosis (93%). Conclusion. Special stains should be done on all granulomatous inflammation cases seen on FNAC for confirmation of TB and ruling out other infectious causes.