A CASE SERIES OF RARE PRESENTATION OF TUBERCULOSIS, POST RENAL TRANSPLANT.

Tuberculosis (TB) remains a global health challenge, especially in immunocompromised patients, such as solid organ transplant recipients. While post-kidney transplant pulmonary TB is frequently reported, extrapulmonary manifestations like intestinal TB are rare and often difficult to diagnose and manage. This case series aims to highlights three unique presentations of post-transplant intestinal TB, emphasizing the diagnostic and therapeutic complexities involved.

This is a Single Center Retrospective Observation of Post-Transplant Rare Case of tuberculosis. 

Case 1:A 32-year-old female Cod patient, post-kidney transplant recipient, presented with severe backache 18 months post-transplant and a history of low-grade fever for 2 months. The donor was her husband (ABO compatible, HLA mismatch 5/6). She was on triple immunosuppressants (TAC, MMF, Pred) and had received ATG as an induction immunosuppressant. Examination revealed tenderness over the D12, L1, and L2 spine. Investigations showed a creatinine level of 0.9, indicating good graft function. MRI of the doors-lumbar spine revealed a large psoas abscess with erosion of D12 and L1 vertebrae and nerve root compression. CT-guided drainage of the abscess yielded 250 ml of pus, which tested positive for rifampicin-sensitive Mycobacterium tuberculosis. HRCT of the thorax was normal. She was treated with a standard 4-drug anti-tubercular therapy (Rifampicin, INH, Pyrazinamide, Ethambutol), Mycophenolate was stopped, and the Tacrolimus dose was adjusted. She showed significant clinical improvement after 1 month and continued ATT for 18 months. The outcome was a significant reduction in the psoas abscess with preserved renal function.

Case 2:An 18-year-old female, post-kidney transplant recipient, presented with sudden onset generalized tonic-clinic seizures (GTCS) 8 months post-transplant. The donor was her mother (ABO compatible, haplo-matched HLA). She was on triple immunosuppressants (TAC, MMF, Steroid) and had received ATG as an induction immunosuppressant. In the emergency department, GTCS was terminated with Lorazepam, and she was prescribed Levetiracetam as maintenance antiepileptic. Examination revealed left-sided hemiparesis and moderate papilloedema on fundoscopy. Investigations showed a creatinine level of 1.2 mg/dl and a Glasgow Coma Scale (GCS) score of 12/15. NCCT brain revealed a space-occupying lesion (SOL) with perilesional oedema in the right parieto-temporal region. MRI brain with gadolinium contrast suggested possibilities of CNS lymphoma or tuberculoma. Stereotactic brain biopsy showed granuloma with no malignancy, and fungal stain was negative. She was started on four-drug anti-tubercular therapy, MMF was stopped, and the Tacrolimus dose was adjusted. She showed significant improvement in the brain SOL after 3 months and continued ATT for 18 months. The outcome was good graft function, and the patient was doing well.

Case 3:A 48-year-old female, who underwent a kidney transplant in 2016, presented with a febrile illness. She had a medical history of Hepatitis B virus (HBV) infection and type 2 diabetes mellitus (T2DM). She presented with symptoms of fever, chills, and rigor. Laboratory investigations revealed anemia, and she was diagnosed with urosepsis. She was treated with intravenous antibiotics and received packed red blood cell (PRBC) transfusions for her anemia. Although her anemia improved post-transfusion, her fever persisted. Further investigation revealed occult blood in her stool. A colonoscopy was performed, followed by a biopsy of the terminal ileum, which initially suggested Crohn's disease or ileal tuberculosis. Histopathological examination of the biopsy showed granulomatous ileitis with evidence of Mycobacterium tuberculosis, confirming the diagnosis of intestinal tuberculosis. She was promptly started on anti-tubercular therapy.

This case series highlights the diverse and atypical manifestations of tuberculosis in post-kidney transplant recipients, including psoas abscess, cerebral tuberculoma, and intestinal tuberculosis. These presentations underscore the diagnostic challenges posed by TB in immunocompromised patients, often mimicking other conditions and requiring invasive investigations for confirmation. Early recognition and initiation of anti-tubercular therapy, combined with careful adjustment of immunosuppressive regimens, are critical for favourable outcomes. These cases emphasize the need for heightened clinical suspicion and a multidisciplinary approach to manage TB in post-transplant settings effectively, ensuring both infection control and graft preservation.