Tuberculosis in Orthotopic Liver Transplant Patients: Increased Toxicity of Recommended Agents; Cure of Disseminated Infection With Nonconventional Regimens

Meyers, Burt R.; Papanicolaou, Genovefa A.; Sheiner, Patricia A.; Emre, Sukru; Miller, Charles M.

doi:10.1097/00007890-200001150-00013

Cited by 81 publications

(67 citation statements)

References 22 publications

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“…Several authors have reported that standard ATT consisting of INH, RIF, PZA, and ETH or regimens including 1 or more potentially hepatotoxic drugs are effective and well tolerated if the patients are closely monitored 7 (Table 4). However, in a study by Meyers et al, 6 standard ATT (triple or quadruple therapy) had to be stopped in 5 of 6 patients (83.3%) and replaced with an alternative regimen consisting of 2 anti-TB drugs (ETH and FQ). In a review of the literature from 1967 to 1997 that included 511 patients who presented with TB after solid organ transplantation, INH hepatotoxicity, defined as an increase in aminotransferases alone, was noted in 41% of LT recipients.…”

Section: Discussionmentioning

confidence: 99%

“…1141 The duration of ATT in transplant patients remains poorly defined and differs between studies. Meyers et al 6 proposed treatment for 12 to 18 months. Clemente et al 7 estimated that bactericidal ATT (INH, RIF, and PZA) required 1 year.…”

Section: Discussionmentioning

confidence: 99%

“…6,7 In addition, the hepatotoxicity of anti-TB drugs is enhanced in transplant patients, mainly because of the function of the graft and interactions with immunosuppressive drugs. 7,8 Guidelines about the treatment of these patients exist in the literature, and they include information about the time to initiate ATT after ALF, the decision to reintroduce or not reintroduce standard ATT (with potentially hepatotoxic drugs), and the effectiveness of alternative nonhepatotoxic anti-TB drugs such as ofloxacin (OFX), ciprofloxacin (CFX), moxifloxacin (MOX), and amikacin (AMK).…”

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Acute liver failure due to antitubercular therapy: Strategy for antitubercular treatment before and after liver transplantation

et al. 2010

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The standard antitubercular treatment (ATT), which consists of isoniazid (INH), rifampicin (RIF), ethambutol, and pyrazinamide (PZA), is the best available treatment for tuberculosis (TB). However, the hepatotoxicity of INH and PZA can be severe, and even after drug withdrawal, patients may require liver transplantation (LT). In these cases, the strategy for the treatment of TB is poorly defined. Between 1986 and 2008, 14 patients presented at our department with severe hepatitis secondary to INH and PZA treatment. Four of these patients were immunosuppressed: 2 after renal transplantation and 2 because of human immunodeficiency virus infection. In seven of the 14 patients an alternative ATT was begun on admission, which was well tolerated. Hepatitis improved spontaneously in 5 patients, and alternative ATT was continued for 9.3 6 4.2 months; 1 patient deteriorated and underwent LT, and 1 patient died. ATT was stopped definitively in 2 patients. Six patients required urgent LT, and alternative ATT was started after transplantation and was successful. Five patients receiving RIF had an episode of acute rejection. In conclusion, hepatitis secondary to ATT can be successfully treated with alternative anti-TB regimens. The use of RIF in LT patients may lead to acute rejection. RIF should therefore be avoided in these patients.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Acute liver failure due to antitubercular therapy: Strategy for antitubercular treatment before and after liver transplantation

et al. 2010

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“…In liver transplant patients, induction therapy with four drugs has been recommended (1,32), while the length of therapy has not been studied in these patients. Therapy for a total of 12-18 months is recommended (1,32).…”

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“…Therapy for a total of 12-18 months is recommended (1,32). Hepatic toxicity is a concern with isonazid in liver transplant patients.…”

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confidence: 99%

Intracranial Tuberculoma in a Liver Transplant Patient: First Reported Case and Review of the Literature

Henderson

Meyers

Gultekin³

et al. 2003

American Journal of Transplantation

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A 66-year-old female who had undergone an orthotopic liver transplant two years before admission was admitted with fever and neurological symptoms of several days' duration. Following an extensive work-up, which revealed positive intracranial lesions on computed typography and magnetic resonance imaging, the patient was begun on broad spectrum antimicrobials including corticosteroids. The patient responded though the etiology of infection remained unclear. After a stereotactic biopsy was performed revealing granulomas and acid-fast bacilli, the patient was started on antituberculous medications. A review of the literature reveals that the rare occurrence of intracranial tuberculoma should be considered in an orthotopic liver transplant (OLT) patient with central nervous system pathology. Case ReportThe incidence and factors associated with tuberculosis in liver transplant patients are not clear (1,2). Tuberculosis involving the central nervous system occurs in only 0.53% of cases of systemic tuberculosis in this country (3). Though intracranial tuberculoma is a common entity in developing countries, cases of tuberculosis involving the central nervous system (either tuberculomas or meningitis) have rarely been reported (4,5). Intracranial tuberculoma in the liver transplant patient has not been previously described. We report a case of a patient who developed neurological symptoms, likely related to intracranial tuberculoma, and died from cerebral hemorrhage. 88An indigenous 66-year-old hispanic female with a history of noninsulin dependent diabetes mellitus, who had a cadaveric liver transplantation for cirrhosis two years earlier, was admitted for confusion, headache, fever, vomiting and diarrhea. The patient was recently discharged after being hospitalized for fever, headache, and confusion without a diagnosis. There was no previous history of tuberculosis in the patient or her family; her purified protein derivative (PPD) status before admission and transplantation was unknown.The patient was in good health several days earlier and was taking prednisone 10 mg qd, cyclosporine 25 mg bid, nystatin, cardiazem and neurontin. The patient denied recent travel, any contact with illness and had no pets.On examination, the patient was febrile, 40.1 aeC, pulse 110 beats/min, blood pressure 133/71 mmHg, respiratory rate 20 breaths/min, and was saturating 98% on room air. She was alert, yet disoriented. No meningismus or adenopathy was noted. Examination of the heart, lungs, and the abdomen was normal. Cranial nerves were intact, and muscle strength was within normal limits, including deep tendon reflexes.Laboratory analysis revealed: hemoglobin, 11.0 g/dL; hematocrit, 31.6%; platelets, 345 ¿ 10 9 /L; white blood cells (WBC), 11.8 ¿ 10 9 /L, with 83.7% neutrophils; sodium, 136 mmol/L; potassium, 3.8 mmol/L; chloride, 101 mmol/L; carbon dioxide, 19; BUN, 60 mmol/L; creatinine, 2.5 mg/dL; glucose, 128 mg/dL; total bilirubin 0.7 mg/dL, direct bilirubin 0.3 mg/ dL, AST Ω 41 U/L, ALT Ω 15 U/L, AP Ω 194 U/L; a PPD was not per...

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Bacterial, Rickettsial and Spirochaetal Infections

Sánchez-Tapias¹

2007

Textbook of Hepatology

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Tuberculosis in Orthotopic Liver Transplant Patients: Increased Toxicity of Recommended Agents; Cure of Disseminated Infection With Nonconventional Regimens

Cited by 81 publications

References 22 publications

Acute liver failure due to antitubercular therapy: Strategy for antitubercular treatment before and after liver transplantation

Acute liver failure due to antitubercular therapy: Strategy for antitubercular treatment before and after liver transplantation

Intracranial Tuberculoma in a Liver Transplant Patient: First Reported Case and Review of the Literature

Bacterial, Rickettsial and Spirochaetal Infections

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