A 60-year-old White, non-Hispanic woman with history of bilateral lung transplant due to severe emphysema presented with painful occipital subcutaneous nodules and a painful right index finger 60 days post-transplant. Induction immunosuppression consisted of basiliximab and maintenance immunosuppression was prednisone, tacrolimus, and mycophenolate. Histologic examination of native lungs showed changes related to smoking (severe emphysema and bronchiolitis), bronchiectasis, and non-necrotizing granulomatous inflammation suggestive of hypersensitivity pneumonitis. Acid-fast bacilli (AFB) and Grocott Methenamine Silver (GMS) stains were negative for organisms. Two days after transplant, the right lung graft was removed due to lobar torsion and infarction. Histologic examination of explanted graft confirmed infarction and AFB stains were also negative. Patient was discharged home on post-operative day 13. Thirty days post-transplant she had declining pulmonary function tests and was treated for presumed rejection with high-dose methylprednisolone for 3 days and rituximab due to presence of donor-specific antibodies. She developed parainfluenza infection on post-transplant day 54 and received methylprednisolone and intravenous immunoglobulin. Sixty days post-transplant she developed painful nodes in the occipital area and painful swelling of the right index finger. Two weeks later, she presented to clinic and was started on linezolid and ceftriaxone for cellulitis. Shortly after completing a 2-week course of antibiotics, pain worsened and she developed nausea, vomiting, chills, and diaphoresis prompting hospital admission. Social history was notable for residing in Kansas, and never having lived or traveled outside the United States. She had dogs and cats but denied bites or scratches. She denied exposure to livestock or other animals, recent water exposures, remote traumatic injuries, gardening, or other outdoor work. She denied consumption of unpasteurized dairy products. She had no history of incarceration or homelessness.
On examination, she was afebrile and well-appearing. She had two exquisitely tender, non-mobile nodules in her occiput without overlying skin discoloration or drainage. There was no cervical, axillary, or inguinal lymphadenopathy. Her right index finger was edematous and erythematous, with limited range of motion. Right-sided breath sounds were absent and left lung was clear to auscultation. There was no abdominal tenderness, hepatosplenomegaly, or rash. Laboratory studies were notable for leukopenia with 3 x 109 cells/liter with lymphopenia of 0.6 x 109 cells/liter.
Non-contrasted chest computed tomography showed new, numerous hypoattenuating liver lesions. Abdominal magnetic resonance imaging (MRI) showed multiple rim-enhancing hepatic lesions suggestive of multifocal abscesses. Right-hand MRI showed a peripherally enhancing 1.3-cm fluid collection along the palmar aspect of the index finger associated with the flexor tendon sheath. Transthoracic echocardiogram and brain MRI were unremarkable. Extensive infectious work-up remained negative.
The patient underwent core needle biopsy of liver lesions and finger incision and drainage. Direct staining of finger tissue was positive with 1-9 acid fast bacilli (AFB)/10 high-power field and empiric treatment for disseminated non-tuberculous mycobacteria (NTM) with linezolid, cefoxitin, azithromycin, and moxifloxacin was promptly initiated. Both liver and tendon histopathology noted granulomatous inflammation with AFB (Figures 1 and 2). Finger and liver tissue cultures grew AFB after 4 days identified by matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry as Mycobacterium tuberculosis complex. Antimicrobial susceptibility testing was performed, and isolate showed susceptibility to ethambutol, isoniazid, pyrazinamide, and rifampin. The patient was started on TB induction therapy with rifabutin (to avoid interaction between rifampin and tacrolimus), isoniazid, pyrazinamide, and ethambutol. AFB sputum, blood, and urine cultures remained negative after 8 weeks. Mycophenolate was held and prednisone and tacrolimus were continued. Patient received 2 months of 4-drug induction treatment followed by 10 months of rifabutin and isoniazid for a total of 12 months of treatment.
The organ donor was originally from Mexico and did not have known medical history. The cause of death was cerebral hemorrhage. There was no information available regarding prior TB testing or treatment. No other recipients have thus far developed TB.