Various clinical presentations of tuberculosis in heart transplant recipients

The purpose of this study was to clarify the various clinical presentations, incidence, and complications associated with tuberculosis (TB), as well as patient survival in heart transplantation (HTx) recipients. A retrospective review of 177 case records of HTx recipients from May 1989 to April 2003 were evaluated for their clinical course, diagnostic procedures, treatment, and survival. TB was diagnosed by culture. TB was proven in five (2.8%) patients. There were three pulmonary lesions and two extrapulmonary lesions. TB was diagnosed at 3.5 to 85 months after HTx. Pulmonary lesions were detected by cultures of sputum, bronchoalveolar lavage, or pleural effusion. For extrapulmonay lesions, one subject had neck lymphadenopathy shown by biopsy and culture to be TB; another suffered from swelling of the finger joints which upon culture of the aspirate proved to be TB. Treatment consisted of isoniazid (INH), rifampin (RIF), ethambutol, pyrazinamide, streptomycin (STR), ciprofloxacin (Ciproxin), and levofloxacin (Cravit). During the use of RIF, the daily dosage of cyclosporine (CsA) or tacrolimus was increased to maintain appropriate levels. Because of severe hepatotoxicity and interference with CsA, RIF was withdrawn and STR given in the last three patients. In addition, ciprofloxacin was given in the patient with miliary TB. Levofloxacin was given to the other two patients. All patients survived the TB infection under treatment with at least three drugs. There were five clinical presentations of TB in our HTx recipients. Because of the high incidence of hepatitis and severe drug interaction with CsA or tacrolimus on RIF treatment, avoiding the use of RIF but treatment with at least three drugs is recommended.