C WILKINSON1,2, D JEGATHEESAN3, G KAN1,2, V MANICKAM1,2, V SRIVASTAVA1,2 , S CAMPBELL3
1The Townsville Hospital, Queensland; 2James Cook University Clinical School, Queensland; 3University of Queensland at the Princess Alexandra Hospital, Queensland
Background: Post-transplant tuberculosis (PTTB) is not uncommon in endemic tuberculosis (TB) areas. It generally represents reactivation of latent TB and 50-60% of cases occur within 12 months post-transplant. Risk factors include acute transplant rejection, concurrent cytomegalovirus (CMV), and HIV infection. TB in Australia has an incidence of 5-7 cases per 100 000, but amongst overseas-born Australians is 19 per 100 000.
Case report: A 47 year old Phillipines-born female received a deceased donor renal transplant; CMV positive to negative, for ESKD secondary to IgA nephropathy in 2013. Pre-transplant TB and HIV screening was negative. She received basiliximab induction and was maintained on tacrolimus, mycophenolate and prednisolone. There was no early rejection. She presented in March 2017 with fevers and diarrhoea of 10 days duration but no other positive symptoms. Radiographic investigations revealed tubo-ovarian collection associated with diffuse abdominal lymphadenopathy and terminal ileum thickening. She underwent laparoscopic drainage with bilateral salpingectomy and oophorectomy; initial histology showed necrotic granuloma and TB was confirmed on culture. She was commenced on a regime of rifabutin, isoniazid, pyrazinamide and ethambutol. Rifabutin was pre-emptively used in place of rifampicin to reduce drug interaction with tacrolimus. Graft function deteriorated in the setting of dehydration contributed by nausea, diarrhoea and oral mucosal HSV co-infection; recovering when oral intake was restored. Tacrolimus dosing required close monitoring and titration within the first month of treatment.
Conclusion: PTTB is not uncommon in endemic areas and should be considered in at risk patients in non-endemic areas. The above anti-TB regime interacts with tacrolimus however there was no rejection observed.