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TRANSPLANT CASE STUDY

This case study examines a tuberculosis infection in an organ transplant recipient, highlighting the epidemiological and clinical features, current screening practices, and reporting pathways for transplant-associated tuberculosis. The study also discusses the management and treatment of the infection in other organ recipients.

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TRANSPLANT CASE STUDY

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  1. TRANSPLANT CASE STUDY Jeanne Soukup, RN, PHN Nurse Manager County of Los Angeles Tuberculosis Control Program

  2. DISCLAIMER • The speaker has no commercial or financial conflict of interest • The use of fluoroquinolone for TB is not currently FDA approved.

  3. OBJECTIVES • Describe the epidemiologic and clinical features of tuberculosis disease in California’s organ transplant population • Understand current TB screening practices for organ transplant donors and recipients • Become familiar with pathway for reporting transplant-associated TB

  4. INDEX PATIENT/TRANSPLANT RECIPIENT • PMH: Rheumatoid Arthritis/ Interstitial Lung Disease w/ combined pulmonary fibrosis and emphysema, pulmonary HTN • Hx of + QFT and had been on INH • 11/23/17 underwent bilateral lung transplant • Donor lung with swab + for rare AFB, MTB PCR –MTB detected

  5. INDEX PATIENT/TRANSPLANT RECIPIENT

  6. INDEX PATIENT/TRANSPLANT RECIPIENT Additional medications: Azithromycin, Moxifloxacin, Vancomycin, Prednisone 40 mg qday, decreased to 25 mg Tacrolimus 1 mg BID Posaconazole 300mg

  7. INDEX PATIENT/TRANSPLANT RECIPIENT • Patient discharged 12/15/17 to home • Culture conversion 1/11/18 • Isolate pan-sensitive • Patient continued treatment with his private provider with public health oversight • PZA and EMB discontinued after 8 weeks • Patient did well in the outpatient setting with monthly home visits by the PHN • completed treatment 5/31/18

  8. DONOR • 18 year old Hispanic male, born in the US • History of incarceration in both juvenile and adult setting • 9/27/17 CXR taken in jail as part of booking process read as normal • 11/17/17 Suffered traumatic brain injury, emergently intubated, progressed to brain death • Family consented to organ donation

  9. DONOR • No documented history of prior test for TB infection • Family reportedly denied patient had travel within 6 months • 11/18/17 CXR Significant lucency throughout the abdomen suspicious for pneumoperitoneum. No acute lung parenchymal or pleural abnormalities. • 11/21/17 Pre-transplant BAL smear negative, no PCR performed; culture later grew MTBc • 11/22/17 CXR Mild right lower lobe infiltrate.

  10. DONOR Pre Accident CXR 9/27/2017

  11. NOTIFICATION AND FOLLOW UP • 11/27/17 case report received at TBCP • 11/28/17 TBCP notified State TB Control Branch Liaison • 11/29/17 informed by hospital transplant coordinator appropriate transplant agencies were notified of positive PCR; formal report filed • Informed that the transplant agency would notify CDC • 12/15/17 contacted by California TB Control Branch regarding BOOTS request for genotyping

  12. Genotyping • Isolates were requested to be sent for genotyping • Needed to wait for donor isolate to grow but eventually MTBc was identified and isolate was sent • Confusion as to the source of the isolates as the 11/23/18 donor specimen was labeled with recipient’s name • Confirmed the source of 3 isolates • Isolates sent for genotyping

  13. Genotyping • Isolates submitted for genotyping • 11/21/17 donor pre-harvest BAL isolate • 11/23/17 donor post-harvest, pre-transplant BAL • 11/24/17 post transplant isolate (recipient) All three isolates had matching Gentype

  14. Molecular Detection of Drug Resistance • Request for MDDR testing from another State • LAC had not requested MDDR since an initial GeneXpert did not identify Rif resistance • This jurisdiction was treating with a quinolone and was awaiting MDDR results • MDDR requested and no mutations associated with resistance detected • pncA mutation was detected however the effect of this mutation on PZA resistance is unknown

  15. Conventional DST • Conventional second line DSTs performed by CDC found isolate sensitive to all drugs tested including PZA

  16. Other Organ Recipients • Heart Recipient: • Prior to transplant had negative IGRA (QFT-TB-G) • Post-transplant had positive IGRA (QFT-TB-G) • CXR-negative • Started on INH, Rifabutin, EMB and PZA • Remained asymptomatic for TB

  17. Other Organ Recipients • Right Kidney • No pre-transplant test for TB Infection • Post-transplant indeterminate QFT-TB-G • Multiple urine samples for AFB negative • Started on INH, EMB, PZA and Moxi • PZA stopped after 2 months with plan to treat for 12 months • No concern for active TB

  18. Other Organ Recipients • Left Kidney/Pancreas • Prior to transplant had negative IGRA (QFT-TB-G) • Post transplant negative IGRA (QFT-TB-G) • No TB symptoms

  19. Other Organ Recipients • Liver • No pre-transplant test for TB Infection • Post-transplant negative IGRA (QFT-TB-G) • Started on Moxifloxacin, INH, EMB, PZA • EMB and PZA stopped after 6 weeks • Moxifloxacin and INH stopped after 6 months

  20. Take Home Points • Notify your State Liaison early in the process as they can provide valuable assistance • Clarify which agencies have been notified and the role they will take in the investigation • Order PCR, MDDR and expedite genotyping • Notify exposed contacts

  21. Questions????

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