Extrapulmonary Tuberculosis in Liver Transplant Recipients: Case Series

Introduction: Tuberculosis (TB) can be a lethal infection in post-transplant patients with a high morbidity and mortality. We report 2 rare cases of post-liver transplant TB. Case 1: A 53-year-old white male with end-stage liver disease from primary sclerosing cholangitis underwent orthotopic liver transplantation. Six months following transplantation he was admitted with upper abdominal pain, fatigue, fevers, and chills. Chest radiograph was unremarkable. Computerized tomography (CT) of the abdomen showed retroperitoneal adenopathy. He had travelled extensively in Southeast Asia on business prior to his transplantation. Before liver transplantation patient had a normal chest x-ray and was angergic for Tuberculin skin test. He underwent endoscopic ultrasound-guided periduodenal lymph node aspiration. The aspirate showed granulomatous inflammation with necrosis with numerous acid fast bacilli. Case 2: A 52-year-old Filipino female with end-stage liver disease from primary sclerosing cholangitis/autoimmune overlap underwent orthotopic liver transplantation. Before liver transplantation she had a normal chest x-ray and negative interferon gamma release assay test. She presented 3 years following the liver transplant with abdominal pain, nausea, and 2 weeks of diarrhea. She had travelled to the Philippines 6 months prior to the onset of her symptoms. Abdominal CT scan showed marked thickening and mucosal enhancement of the second and third portion of the duodenum, as well as the terminal ileum associated with luminal narrowing. The duodenal biopsy revealed severe duodenitis with ulceration, necrotizing and non-necrotizing granulomatous inflammation. AFB stain highlighted a single organism consistent with Mycobacterium. Discussion: Post-transplant patients acquire TB either by reactivation of latent TB, from close contacts with active TB or rarely following transplantation of infected organ. Majority of post-transplant patients acquire TB during first year following transplantation. The rise in the in incidence of TB following transplant is due to suppression of the cell-mediated immunity. There may be a delay in diagnosis due to atypical presentation, but clinicians should consider extrapulmonary TB. The standard treatment for extrapulmonary tuberculosis in post-liver transplant is similar to pulmonary TB with quadruple-drug regimen (INH, rifampicin, pyrizinamide, and ethambutol). Conclusion: Post-transplant TB should be considered in liver transplant recipients with unexplained fever and lymphadenopathy, particularly in patients who have traveled or who are from endemic areas, even if there are no respiratory symptoms.