CLINICAL PRESENTATION AND OUTCOME OF TUBERCULOSIS IN KIDNEY, LIVER, AND HEART-TRANSPLANT RECIPIENTS IN SPAIN

Background. Tuberculosis is unusual in transplant recipients. The inci dence, clinical manifestations, and optimal treatment of this disease in this population has not been adequately defined. The present study was undertaken to assess the incidence, clinical features, and respons e to therapy of Mycobacterium tuberculosis infection in solid-organ tr ansplant recipients. Methods. We evaluated retrospectively the inciden ce, clinical characteristics, diagnostic procedures, antituberculous t reatment, clinical course, and factors influencing mortality in 51 sol id-organ transplant recipients who developed tuberculosis after transp lantation. We also reviewed the world literature on tuberculosis in so lid-organ transplantation. Results. The overall incidence of tuberculo sis was 0.8%. The localization was pulmonary in 63% of the cases, diss eminated in 25%, and extrapulmonary in 12%. Tuberculosis developed fro m 15 days to 13 years after surgery (mean, 23 months). In one third of the cases, diagnosis was not suspected initially, and in three cases, diagnosis was made at necropsy. Fever was the most frequent symptom, followed by constitutional symptoms, cough, respiratory insufficiency, and pleuritic pain. Fifteen patients (33%) developed hepatotoxicity d uring treatment; hepatotoxicity was severe in seven cases. Hepatotoxic ity was higher in patients receiving four or more antituberculous drug s (50%) than in patients receiving three drugs (21%; P=0.03). Serum le vels of cyclosporine decreased in the 26 patients under the simultaneo us use of rifampin. Nine of them (35%) developed acute rejection, and five (56%) died, in comparison with 3 of 17 patients (18%) who did not develop rejection after the use of cyclosporine and rifampin (P=0.03) . Although microbiological response was favorable in 94% of the 35 pat ients who completed 6 or more months of treatment, 16 other patients ( 31%) died before diagnosis or in the course of treatment. None of the patients treated for more than 9 months died as a consequence of tuber culosis, whereas the mortality rate was 33% among those treated for 6 to 9 months (P=0.03). Use of antilymphocyte antibodies or high doses o f steroids for acute rejection before tuberculosis was associated with a higher mortality rate. Conclusions. M tuberculosis causes serious a nd potentially life-threatening disease in solid-organ transplant reci pients. Treatment with at least three drugs during 9 months or more, a voiding the use of rifampin, appears to be appropriate.