Regmi A, Singh P, Harford A
Nephrology Division, Department of Internal Medicine, The University of New Mexico Health Science Center, Albuquerque, New Mexico.
Nephrology Division, Department of Internal Medicine, The University of New Mexico Health Science Center, Albuquerque, New Mexico.
Transplant Proc. 2014 Jan-Feb;46(1):274-7. doi: 10.1016/j.transproceed.2013.07.071.
Tuberculosis (TB) is a common opportunistic infection after renal transplantation. The risk of TB in renal transplant recipients is reported to be 20 to 74 times higher than in the general population. Although extrapulmonary TB occurs frequently, isolated ankle joint TB is a rare form of extrapulmonary TB infection. It is often difficult to diagnose because of its atypical presentation; management is complex, especially with multidrug-resistant TB, the need for a prolonged course of therapy, and the risks of drug interactions and drug toxicity. We report herein a case of a 60-year-old female renal allograft recipient who developed multidrug-resistant ankle joint TB 11 months after her deceased donor renal transplantation. She presented to the emergency department with escalating pain and swelling of the left ankle, difficulty in ambulation, and a low-grade fever. An x-ray of the ankle revealed an effusion and soft tissue swelling. A synovial fluid culture was performed which tested positive for acid fast bacilli which grew a multidrug-resistant form of Mycobacterium tuberculosis. She was initially treated with isoniazid, rifampin, ethambutol, and pyrazinamide; then therapy was tailored secondary to the resistant nature of the organism. She received a combination of extensive debridement of the joint and institution of second-line anti-TB therapy with pyrazinamide, ethambutol, moxifloxacin, and ethionamide. To our knowledge, no other cases of multidrug-resistant TB have been reported in the literature after renal transplantation. This case shows both an atypical presentation of TB and the difficulties in managing a transplant patient with this disease.
结核病（TB）是肾移植后常见的机会性感染。据报道，肾移植受者患结核病的风险比普通人群高20至74倍。尽管肺外结核经常发生，但孤立性踝关节结核是肺外结核感染的一种罕见形式。由于其非典型表现，往往难以诊断；治疗复杂，尤其是对于耐多药结核病，需要延长疗程，且存在药物相互作用和药物毒性的风险。我们在此报告一例60岁女性肾移植受者的病例，她在接受已故供体肾移植11个月后发生了耐多药踝关节结核。她因左踝关节疼痛和肿胀加剧、行走困难以及低热而就诊于急诊科。踝关节X线检查显示有积液和软组织肿胀。进行了滑液培养，结果显示抗酸杆菌检测呈阳性，培养出耐多药形式的结核分枝杆菌。她最初接受异烟肼、利福平、乙胺丁醇和吡嗪酰胺治疗；然后根据病原体的耐药性质调整治疗方案。她接受了关节广泛清创术，并采用吡嗪酰胺、乙胺丁醇、莫西沙星和乙硫异烟胺进行二线抗结核治疗。据我们所知，文献中尚未报道肾移植后发生其他耐多药结核病病例。该病例既显示了结核病的非典型表现，也显示了管理患有这种疾病的移植患者的困难。
