Tuberculosis in Solid Organ Transplantation: Insights from TB Endemic Areas

The incidence of tuberculosis (TB) is many fold higher in transplant recipients than in the general population with the highest risk in first year post-transplant. The purpose of this review is to describe the epidemiology, clinical characteristics, management, and outcomes of TB in organ transplant recipients from TB endemic regions and highlight the challenges faced in their management. TB can be increasingly difficult to diagnose and manage in transplant recipients. Clinical manifestations are often atypical leading to delay in diagnosis and available diagnostic modalities are limited in their ability to accurately detect TB. Moreover, the treatment of TB is particularly difficult owing to drug–drug interactions with post-transplant medications. Hence, the focus of recent research has been identification and treatment of latent TB infection pre-transplant. The prevalence of TB in transplant recipients is reportedly 12% in TB endemic countries compared to 5% in developed countries. The risk is greatest among transplant recipients with residence in a country with high TB burden. The clinical presentation can vary from the classic symptoms to unusual extrapulmonary manifestations, particularly involvement of genitourinary tract in renal transplant recipients. The first-line treatment is similar to that for immunocompetent patients but requires greater vigilance in monitoring of side effects, particularly hepatotoxicity. Longer treatment duration may be needed in those in whom a first-line regimen could not be used or those with drug-resistant TB. All transplant recipients should be screened for latent TB infection (LTBI) and given prophylaxis if found to have evidence of LTBI.