Should We Assess the Donor's Lymph Nodes during Lung Procurement? How to Manage When Lymph Node Tuberculosis is Found

Introduction Donor Derived Tuberculosis (TB) after solid organ transplantation is a rare, but deadly, complication, more common in lung transplant (TXP) patients. In brain dead donors the information to rule out latent or active TB is usually not available.The systematic assessment of lymph nodes (LN) is not part of the current techniques described for lung procurement. In fact only in the backtable after lung excision are most LN accessible for evaluation. Case Report We present 2 cases in which during backtable evaluation the LN were considered suspicious and sent for evaluation.Since no guideline addresses this situation we carried on with the transplants. In both cases the report for the LN came back positive in the Ziehl-Neelsen stain and granulomas confirming the presence of TB. Case 1 44 year-old man with COPD. His donor was a 40 year-old man, with cerebral edema post-hyponatremia, with a psychiatric disorder but no other history.The patient underwent a bilateral lung TXP under VA ECMO, he was extubated on day 3 and was discharged 30 days after the TXP. As soon as the diagnosis of the donor was known he started antibacilar treatment (HRZE).His bronchoalveolar lavage, was negative for acid-fastness but the nucleic acid amplification was positive.The patient completed 9 months of therapy. He later developed renal dysfunction, 11 months after the transplant. He now has a follow-up of 3 years 7 months with no evidence of active TB but he did develop chronic rejection and has now been proposed for a re-transplant.Case 2 65 year-old man with COPD. His donor was a 45 year-old man, with liver cirrhosis, whose cause of brain death was a ruptured brain aneurism.The patient underwent a bilateral lung TXP, we was extubated on day 1 and was discharged on the 40th day post TXP. He now has 1 year and 2 months post transplant, he had liver dysfunction after 2 months of HRZE so after normalization of liver function he completed a further 6 months of HR. No evidence of TB has been found. Summary The thorough evaluation of the donors’ lungs should also include their lymph nodes. If the surgeon finds them suspicious, specially in zones with higher incidence of tuberculosis, pathology and microbiology investigation should be made, so that proper treatment can be started before any symptoms occur since the presence of clinically active TB can be deadly, specially in this immunosuppressed group.