1. Tuberculosis Control Program
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
Date/Time
Specimen
Smear
PCR
Culture
11/18/2017
0443pm
Resp, lower
Trach suction
negative
11/23/2017
1048am
Resp lower
Bronchial wash* 1+
positive
MTBc
11/24/2017
118pm
BAL
positive 
11/27/2017
1016
11/29/2017
1630
N/D 
12/01/2017
0953
1/11/2018
N/D

6. INDEX PATIENT/TRANSPLANT RECIPIENT
Medications
Dosage
Start
Isoniazid
300
11/25/2017
Rifabutin
Ethambutol
1600
Pyrazinamide
2000 B6 25
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????