Immune Reconstitution Inflammatory Syndrome Occurring in a Kidney Transplant Patient with Extrapulmonary Tuberculosis

Abstract

Tuberculosis (TB) occurring in solid organ transplantation (SOT) is associated with significant morbidity and mortality usually due to delays in diagnosis, drug toxicity encountered with antimycobacterial therapy, and drug-drug interactions. TB in SOT patients may mimic other infectious and noninfectious posttransplant complications such as posttransplant lymphoproliferative disorder (PTLD) and systemic cytomegalovirus infection. Immune reconstitution inflammatory syndrome (IRIS) is a host response resulting in paradoxical worsening of an infectious disease which occurs after the employment of effective therapy and reversal of an immunosuppressed state. We describe the development of immune reconstitution inflammatory syndrome (IRIS), a unique complication occurring during the treatment of extrapulmonary tuberculosis occurring after transplant which resulted from decreasing immunosuppression in a patient who received Alemtuzumab induction therapy. Although (IRIS) has been originally described in HIV/AIDS patients receiving highly active antiretroviral therapy (HAART), solid organ transplant recipients with diagnosed or occult TB whose immune system may undergo immune reconstitution during their posttransplant course represent a new high risk group.

Immunosuppressive Agents and Infectious Risk in Transplantation: Managing the “Net State of Immunosuppression”

“…Resolution of tuberculosis requires intact innate and adaptive immunity with minimization of immunosuppression and treatment of intercurrent CMV infections. Tuberculous meningitis may preclude rapid reductions in immunosuppression (notably corticosteroids) given risks of ventricular obstruction and hydrocephalus with immune reconstitution [245,246].…”

Tuberculosis IRIS: Pathogenesis, Presentation, and Management across the Spectrum of Disease

“…In this review we will detail the current state of research on each form of TB-IRIS and describe the gaps in understanding that may serve as opportunities for future study. While TB-IRIS may occur in settings outside of HIV co-infection (for example, with a decrease in immune suppressive medications related to transplantation), the focus of this review relates to HIV [9].…”

Tuberculosis in Pediatric Solid Organ and Hematopoietic Stem Cell Recipients

“…Risk factors for post-transplant TB in SOT recipients include social factors; 27 - 29 infectious disease history and co-infections; 24 , 27 - 31 underlying clinical conditions; 24 , 27 , 28 , 30 - 32 type of organ transplanted 33 , 34 ; immunosuppressive therapies, particularly T-cell depleting antibodies 24 , 27 , 28 , 30 , 31 , 34 - 36 ; and transplant complications 30 ( Table 1 ).…”