Apresentação radiológica da tuberculose pulmonar ativa em transplantados renais: um estudo retrospectivo de quatro casos e revisão da literatura

Oliveira, Virgilio de Araujo; Almeida, Ricardo Augusto Monteiro de Barros; Cavalcante, Ricardo de Souza; Andrade, Luis Gustavo Modelli de; Ribeiro, Sergio Marrone

Virgilio de Araujo Oliveira

Faculdade de Medicina de Botucatu, Universidade Estadual Paulista “Júlio de Mesquita Filho” (UNESP). Botucatu, SP, Brazil

https://orcid.org/0000-0003-4838-4878

Ricardo Augusto Monteiro de Barros Almeida

Faculdade de Medicina de Botucatu, Universidade Estadual Paulista “Júlio de Mesquita Filho” (UNESP). Botucatu, SP, Brazil

https://orcid.org/0000-0003-0567-6221

Ricardo de Souza Cavalcante

Faculdade de Medicina de Botucatu, Universidade Estadual Paulista “Júlio de Mesquita Filho” (UNESP). Botucatu, SP, Brazil

https://orcid.org/0000-0001-6382-2675

Luis Gustavo Modelli de Andrade

Faculdade de Medicina de Botucatu, Universidade Estadual Paulista “Júlio de Mesquita Filho” (UNESP). Botucatu, SP, Brazil

https://orcid.org/0000-0002-0230-0766

Sergio Marrone Ribeiro Correspondence: Dr. Sergio M. Ribeiro. Departamento de Doenças Tropicais e Diagnóstico por Imagem, Faculdade de Medicina de Botucatu, Unesp. Distrito de Rubião Júnior, s/n. Botucatu, SP, Brazil, 18618-970. Email: sergio.ribeiro@unesp.br

Faculdade de Medicina de Botucatu, Universidade Estadual Paulista “Júlio de Mesquita Filho” (UNESP). Botucatu, SP, Brazil

https://orcid.org/0000-0003-0732-2814

Correspondence: Dr. Sergio M. Ribeiro. Departamento de Doenças Tropicais e Diagnóstico por Imagem, Faculdade de Medicina de Botucatu, Unesp. Distrito de Rubião Júnior, s/n. Botucatu, SP, Brazil, 18618-970. Email: sergio.ribeiro@unesp.br

Figuras (4)
Tabelas (3)

Thumbnail

Figure 1
Chest X-ray (A,B) and HRCT (C) of a 66-year-old male with pulmonary TB (patient 1) showing consolidation with central cavitation (white arrows). On HRCT, a tree-in-bud pattern was seen at multiple sites, including the upper segment of the left lower lobe (black arrows).

Thumbnail

Figure 2
Chest X-ray (A,B) and HRCT (C) of a 41-year-old female with pulmonary TB (patient 2). A,B: Chest X-ray showing a miliary pattern (white arrows). C: HRCT showing small centrilobular nodules with branching (open arrow) and airspace nodules (black arrow).

Thumbnail

Figure 3
Chest X-ray (A) and HRCT (B,C) of a 58-year-old female with pulmonary TB (patient 3). A: Chest X-ray showing a reticular pattern characterized by mild interstitial opacity in the upper right lung (white arrows), better visualized on HRCT. B,C: HRCT showing a tree-in-bud pattern (black arrows).

Thumbnail

Figure 4
Chest X-ray (A,B) and HRCT (C) of a 53-year-old female with pulmonary TB (patient 4). A,B: Chest X-ray showing no lung abnormalities. C: HRCT showing a tree-in-bud pattern (white arrow) and ground-glass opacity (black arrows).

Thumbnail

Table 1
Demographic, epidemiological, clinical, diagnostic and therapeutic characteristics of patients submitted to KTX and diagnosed with active pulmonary TB.

Thumbnail

Table 2
Chest X-ray and HRCT findings in patients undergoing KTX and diagnosed with pulmonary TB.

Thumbnail

Table 3
Comparison among the radiological findings of Pereira et al.(¹²12 Pereira M, Gazzoni FF, Marchiori E, et al. High-resolution CT findings of pulmonary Mycobacterium tuberculosis infection in renal transplant recipients. Br J Radiol. 2016;89:20150686.), Wu et al.(¹³13 Wu W, Yang M, Xu M, et al. Diagnostic delay and mortality of active tuberculosis in patients after kidney transplantation in a tertiary care hospital in China. PLoS One. 2018;13:e0195695.), Gandhi et al.(¹⁵15 Gandhi S, Kute V, Patel KN, et al. Role of high-resolution computed tomography of chest in posttransplant pulmonary infection. Indian J Transplant. 2017;11:49-54.), and the present study, in KTRs with pulmonary TB.

Variable	Patient
Variable	1	2	3	4
Age at transplantation (years)	62	34	57	50
Age at pulmonary TB diagnosis (years)	65	41	58	53
Sex	Male	Female	Female	Female
Race	Black	Mixed	Mixed	White
Etiology of CKD	Hypertension	Undetermined	Hypertension/lithiasis	Hypertension
Type of dialysis	Hemodialysis	Hemodialysis	Hemodialysis	Peritoneal
Time on dialysis (months)	45	18	82	88
HIV/hepatitis C virus/hepatitis B surface antigen	No/No/No	No/No/No	No/No/No	No/No/No
Diabetes mellitus	No	No	No	No
Current/former smoker	No/No	No/Yes	No/Yes	No/Yes
Current/former alcoholic	No/Yes	No/No	No/No	NR/NR
Prior TB	No	No	No	No
Contact with an active TB case	No	No	No	No
Prior prophylaxis against TB	No	No	No	No
Date of KTX	3/26/2011	8/8/2009	4/12/2015	3/8/2014
Type of donor	Deceased	Deceased	Deceased	Deceased
Immunosupression induction therapy	Anti-CD25 antibody	Not reported	Anti-CD25 antibody	ATG
Immunosupression maintenance therapy	SRL+MPS+PD	FK+SRL+PD	FK+MPS+PD	FK+MPS+PD
Immunosupression intensification in the last 6 months	No	No	No	No
Days from KTX to pulmonary TB diagnosis	1,311	2,432	143	1,165
Symptoms
Chest pain	Yes	No	No	No
Fever	Yes	Yes	Yes	No
Appetite loss	Yes	Yes	No	No
Weight loss	Yes	Yes	No	No
Sweating	Yes	Yes	No	No
Productive cough	Yes	Yes	No	Yes
Dry cough	No	No	No	Yes
Dyspnea	No	No	No	Yes
Lymph node enlargement	No	No	Yes	No
Creatine clearance at pulmonary TB diagnosis (mL/m)	46	24	68	19
Clinical basis of the diagnosis of pulmonary TB	SSM+/SC+	SSM+/SC+	BALFC+	SSM+
Signs of active TB at other sites	Peritoneum	Cecum	Lymph node(s)	No
R/l/P/E sensitivity	NA	Yes/Yes/NA/Yes	Yes/Yes/NA/Yes	NA
TB treatment	R/l/P/E	LFX/E/S	R/l/P/E	R/l/P/E
TB treatment duration (months)	12	12	12	9
Follow-up after pulmonary TB diagnosis (days)	1,243	686	930	310
Clinical cure	Yes	Yes	Yes	Yes
Complications
Deep vein thrombosis	Yes	Yes	No	No
Anemia	No	Yes	No	No
Colonization with M. gordonae	Yes	No	No	No
R/l/P/E hepatotoxicity	No	Yes	No	No
Sequelae	No	No	No	No
Acute rejection	No	No	No	Yes
Graft loss	No	No	No	No
Death	No	No	No	No

Patient	Chest X-ray findings	Chest HRCT findings
1	Alveolar opacity, with central cavitation, in the left upper lobe	Consolidation, with central cavitation in the apicoposterior segment of the left upper lobe Small centrilobular nodules, some showing branching (tree-in-bud pattern) and others coalescing, together with interstitial opacities in the upper segment of the lower left lobe Five mediastinal lymph nodes, less than 1 cm in size, in subcarinal chains and the right hilum, presenting complete, dense, homogeneous calcifications
2	Diffuse reticulonodular interstitial opacity with a miliary pattern	Bilateral random/miliary distribution, together with a tree-in-bud pattern Airspace nodules, some coalescing and forming small areas of consolidation, mainly in the upper lobes
3	Poorly defined reticular pattern in the right upper lobe	Small centrilobular nodules with branching (tree-in-bud pattern), some coalescing and forming small areas of consolidation in the posterior and apical segments of the right upper lobe
4	No abnormalities	Small centrilobular nodules, with branching (a tree-in-bud pattern) in areas of ground-glass opacity, in the anterior segment of the left upper lobe and medial basal segment of the left lower lobe

Imaging finding	Pereira et al.(¹²12 Pereira M, Gazzoni FF, Marchiori E, et al. High-resolution CT findings of pulmonary Mycobacterium tuberculosis infection in renal transplant recipients. Br J Radiol. 2016;89:20150686.) (N = 40)	Wu et al.(¹³13 Wu W, Yang M, Xu M, et al. Diagnostic delay and mortality of active tuberculosis in patients after kidney transplantation in a tertiary care hospital in China. PLoS One. 2018;13:e0195695.) (N = 48)	Gandhi etal.(¹⁵15 Gandhi S, Kute V, Patel KN, et al. Role of high-resolution computed tomography of chest in posttransplant pulmonary infection. Indian J Transplant. 2017;11:49-54.) (N = 16)	Present study (N = 4)
Miliary nodules	16 (40.0%)	8 (16.7%)	3 (18.8%)	1 (25.0%)
Nodule or speckle^* * Not a term recommended by the Fleischner Society(14).	-	33 (68.8%)	2 (12.5%)	-
Centrilobular nodules	9 (22.5%)	-	9 (56.2%)†	4 (100.0%)^† † With a tree-in-bud pattern.
Focal proliferation	-	20 (41.7%)	-	-
Cavitation	9 (22.5%)	5 (10.4%)	7 (43.8%)	1 (25.0%)
Ground-glass opacity	6 (15.0%)	-	0 (0.0%)	1 (25.0%)
Consolidation	6 (15.0%)	3 (6.2%)	7 (43.8%)	3 (75.0%)
Lymphadenopathy	5 (12.5%)	10 (20.8%)	4 (25.0%)	1 (25.0%)
Pleural effusion	4 (10.0%)	15 (31.3%)	1 (6.2%)	0 (0.0%)

[1] Correspondence: Dr. Sergio M. Ribeiro. Departamento de Doenças Tropicais e Diagnóstico por Imagem, Faculdade de Medicina de Botucatu, Unesp. Distrito de Rubião Júnior, s/n. Botucatu, SP, Brazil, 18618-970. Email: sergio.ribeiro@unesp.br

Brasil

Brasil

Apresentação radiológica da tuberculose pulmonar ativa em transplantados renais: um estudo retrospectivo de quatro casos e revisão da literatura

Resumo