A case series of multidrug‐resistant tuberculosis in renal transplant recipients: Challenges in management from a TB endemic country

Abstract

Organ transplantation under necessary concurrent immunosuppression contains a high risk of contracting tuberculosis (TB), and reactivation of dormant TB has been regarded as a predominant mode of acquisition. 1 Living in high endemic area renders these high-risk individuals of getting TB from community and hence it is one of the causes of late-onset TB. Treatment of drug-resistant TB has a longer course as compared to drug-sensitive TB and there are more chances of failure. 2 Pulmonary TB is the frequent site of involvement but extra pulmonary TB is also not rare affecting 16% of cases. 3 Drug toxicity and drug interactions with immunosuppressive agents may result in inadequate immunosuppressive levels that can lead to graft failure. 4 The following is a case series of multidrug-resistant TB (MDR-TB). Transplant physicians and Infectious Diseases specialist managed the patients according to World Health Organization (WHO) guidelines with monthly follow-up of sputum culture and managed drug toxicities.

Multi‐drug resistant and rifampin‐resistant tuberculosis in transplant recipients

“…Of all reports, three each were from Asia, South America, and Europe, and one was from the United States. The majority were SOT recipients – seven kidneys, 5,7,8,10,12 one lung, 9 one heart‐lung, 11 and one heart 6 – and the remaining two cases were allogeneic HCT recipients 4,13 …”

The role of alternative regimens in the management of tuberculosis in transplant recipients: From past challenges to future opportunities

“…Interactions with immunosuppressants are not known, and experience in the treatment of tuberculosis in transplant recipients is scarce and limited to publications of short case series. 8,9 Pretomanid also belongs to the nitroimidazole class of drugs and blocks the biosynthesis of mycolic acid. The main side effects of pretomanid include peripheral neuropathy, acne, anemia, nausea, vomiting, myalgia, headache, hypertransaminasemia, cholestasis, dyspepsia, anorexia, skin rash, pruritus, and abdominal pain.…”

“…The CYP3A4 inhibitors or inducers do not affect exposure. Interactions with immunosuppressants are not known, and experience in the treatment of tuberculosis in transplant recipients is scarce and limited to publications of short case series 8,9 …”

Mycobacterial infections in solid organ transplant recipients

“…MDR-TB is caused by MTB, which is resistant to isoniazid and rifampicin. Reports of MDR-TB cases in transplant patients have been published, although the number is small [ 78 - 82 ]. MDR-TB in SOT recipients is associated with extrapulmonary manifestations, severe treatment complications, and death [ 82 ].…”

“…The authors suggested that these drugs should be urgently made available and accessible to patients with MDR-TB [ 84 ]. However, Babar et al [ 81 ] reported severe drug toxicity with the use of a new drug regimen and concluded that the management of MDR-TB in transplant recipients is challenging; hence, close monitoring and follow-up is needed.…”