Ann Thorac Surg 2009;87:1611-1613. doi:10.1016/j.athoracsur.2008.09.011
© 2009 The Society of Thoracic Surgeons
Case Reports
Successful Treatment of Multi-Drug Resistant Tuberculosis by Double Lung Transplantation
Jing-yu Chen, MD*,
Yan-hong Zhu, MD,
Chao-hui Jin, MD,
Ming-feng Zheng, MD,
Ji Zhang, MD,
Min Zhou, MD
Lung Transplant Group, Wuxi People's Hospital, Wuxi, China
Accepted for publication September 2, 2008.
* Address correspondence to Dr Chen, Wuxi People's Hospital, Room A516, 299 Qing Yang Rd, Wuxi, Jiangsu, 214023, China (Email: chenjingyu333{at}yahoo.com.cn).
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Abstract
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A 24-year-old man suffering from end-stage, multi-drug, resistant tuberculosis and right heart failure underwent bilateral, single-lung transplantation with extracorporeal membrane oxygenator support. He was successfully weaned and discharged from the hospital 30 days later. Sputum cultures have been negative for tuberculosis since discharge, and for almost 2 years thereafter. Anti-tuberculosis medication was discontinued 4 months postoperatively.
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Introduction
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Double lung transplantation is an effective way to deal with the infection pulmonary disease, even though the relative contraindications, including colonization with highly resistant or highly virulent bacteria, fungi, or micobacteria. Although multi-drug, resistant tuberculosis is a contraindication for lung transplantation and was no case report for this until now, our interesting case will show that the lung transplantation may be a possible way to treat the end-stage multi-drug, resistant tuberculosis patients.
A 24-year-old man contracted tuberculosis 6 years prior to presentation. He was experienced with standard first-line and second-line drugs to anti-tuberculosis. But the sputum showed that it was resistant for rifampicin, ethambutol, isoniazid, pyrazinamide, streptomycin, p-amino-salicylic acid, and capreomycin. He had progressive weight loss and decreasing respiratory reserve. After discussion with the local ethics committee, he was considered and accepted for pulmonary transplantation and transferred to our institution from the local tuberculosis hospital with respiratory failure and Biphasic Positive Airway Pressure. Preoperative sputum cultures confirmed multi-drug, resistant tuberculosis. He was too severe to do the pulmonary function test. Arterial oxygen tension was 51 mm Hg, and arterial carbon dioxide tension was 86 mm Hg on 0.5 fraction of inspired oxygen. Echocardiogram showed left ventricular ejection fraction of 56%, with decreased right ventricular function and severe tricuspid regurgitation. Pulmonary artery pressure was 80/60 mm Hg with a systemic pressure of 120/80 mm Hg. The patient was 165 cm and 45 kg. Chest roentgenogram and computed tomographic scan can be seen in Figure 1.
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Fig 1. (A) Preoperative chest roentgenogram and (B) computed tomographic scan showing severe destruction of the right pulmonary parenchyma with large tuberculous cavity. The right thoracic cavity volume is reduced. The left lung also shows evidence of tuberculosis.
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We obtained permission from the local ethics committee, and the consent of the patient for double-lung transplantation.
Nine days after admission, a 22-year-old, 68 kg, 170 cm local male donor became available. He underwent bilateral sternal sparing lung transplantation with extracorporeal membrane oxygenator support [1]. Extracorporeal membrane oxygenator was initiated prior to chest incision through the right femoral artery and vein, which was maintained at 2 L/min. Pulmonary pressure declined to 39/23 mm Hg and systemic pressure to 103/61 mm Hg. Activated clotting time (ACT) was maintained during 150 to 200 seconds. The right lung was removed first. Due to the smaller chest cavity of the recipient compared with the donor, a right lower lobectomy was performed on the donor lung prior to transplantation. The whole left lung was used. The operation was uncomplicated. The extracorporeal membrane oxygenator was successfully weaned 1 hour postoperatively. The patient was re-explored for right pleural hematoma 9 days postoperatively, and the ventilator was weaned 7 days later. The rest of his postoperative stay was uncomplicated. The patient was discharged from the hospital 30 days postoperatively. The chest roentgenogram and computed tomographic scan of the patient, 3 months post-transplantation can be seen in Figure 2.
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Fig 2. The (A) chest roentgenogram and (B) computed tomographic scan of the patient 3 months after the transplantation.
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Pathologic examination of the two explanted lungs confirmed the presence of live tuberculosis bacilli. However, despite this confirmation, tuberculosis was never demonstrated again in the patients' sputum cultures, which were started while the patient was still intubated postoperatively. Bronchoalveolar lavage up to 2 years after surgery has failed to demonstrate any evidence of tuberculosis, despite the discontinuation of anti-tuberculosis treatment 4 months postoperatively. The patient had one episode of acute rejection at 8 months postoperatively treated by pulse steroids (without anti-tuberculous coverage). The patient is currently well on Cellcept (Mycophenolate Mofetil; ROCHE, Basel, Switzerland) and Prograf (Tacrolimus; Fujisawa, Tsukuba, Japan).
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Comment
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Multi-drug resistant tuberculosis is not only more common, but it is especially difficult to treat [2]. The patient will be dead in a few days without the lung transplantation. These patients are potentially dangerous as a source and reservoir of infection for other individuals, and potentially pose great epidemic risk to the general population. While conventional surgery is sometimes helpful, bilateral disease, as our patient demonstrated, makes surgery less effective and does not "solve" the problem. So the local ethics committee permitted us to try the lung transplant. We have demonstrated that double lung transplant, despite attendant immunosuppression, was successful in eradicating infection and curing this patient's disease. This also occurred in the face of an acute rejection episode, which necessitated pulsed steroids (ie, further immunosuppression).
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References
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- Chen JY, Zhen MF, Zhu YH, et al. Lung transplantation for end-stage pulmonary diseases: report of 18 cases Chin J Organ Transplant 2005;26:603-605.
- Cohn D, Bustreo F, Raviglione M. Drug-resistant tuberculosis: review of the worldwide situation and the WHO/IUATLD Global Surveillance Project Clin Infect Dis 1997;24(Suppl 1):S121-S130.[Medline]
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Abstract
Introduction
